HospitalInspections.org

Based on document review and staff interviews, the Board of Governors failed to:

1. Ensure approval of the patient grievance process. Please refer to A-0119.

2. Ensure the nursing staff provided adequate supervision and oversight of patient activities on the child and adolescent unit resulting in the failure to identify and prevent patients from engaging in inappropriate sexual behavior. Please refer to A-0395.

3. Ensure the hospital wide performance improvement program set priorities for the quality improvement program to include patient care data collection to monitor the effectiveness, safety, and quality of patient care. Please refer to A-0273.

4. Ensure the hospital wide performance improvement program developed indicators that allowed identification of high risk, problem prone areas that affect health outcomes, patient safety, and quality of care. Please refer to A-0283.

5. Ensure the hospital wide performance improvement program included the identification, tracking, and investigation of patients' inappropriate behaviors including suicide gestures/attempts, self-harm behaviors, and sexual patient encounters. Please refer to A-0286.

6. Ensure the hospital wide performance improvement program included all services offered at the hospital. Please refer to A-0308.

7. Ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for patients on the adult inpatient behavioral health unit. Please refer to A-0395.

8. Ensure the hospital's staffing contained an adequate numbers of Registered Nurses and Mental Health Technicians to monitor patients placed on 1:1 Observation (1 staff person to 1 patient), as ordered by the physician. Please refer to A-0392 and A-1704.

The cumulative effect of the systemic failure and deficient practices resulted in the hospital's inability to effectively carry out the responsibilities of the hospital to ensure patients received appropriate care and treatment in a safe setting and ensure quality health care provided to patients. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey.

Based on document review and staff interviews, the hospital administrative staff failed to recognize 1 of 1 identified verbal complaints regarding patient care (Patient #1) rose to the level of a grievance, and process the complaint as a grievance. Failure to recognize the telephone call as a grievance and conduct an appropriate investigation into the incident resulted in the hospital staff's failure to address a guardian's concern regarding supervision of adolescent patients and address unrecognized inappropriate sexual activity and behaviors taking place on the children's and adolescent unit. The hospitals administrative staff reported 9 patients on the children's and adolescent unit on entrance.

Findings include:

1. Review of the policy "Managing Patient Grievances," approved 1/2021, revealed in part, "... patient grievance is a formal or informal written or verbal complaint that is made by a patient or the patient's representative regarding the patient's care ... [a grievance] also include situations where a ... patient's representative telephones the hospital with a complaint regarding the patient's care ..."

2. During an interview on 8/17/21 at 12:00 PM, the Nurse Manager verified Guardian #26 called the Nurse Manager and expressed concerns that the nursing staff failed to provide adequate supervision to pediatric patients on the child and adolescent inpatient behavioral health unit, when Patient #5 informed Guardian #26 that Patient #5 witnessed sexual activity between other pediatric patients on the unit. The Nurse Manager believed the CNO would perform the investigation, and Guardian #26 did not want any further follow-up from the hospital staff.

3. Review of an untitled document, provided by the Nurse Manager, dated 8/12/21, revealed a summary of a phone call she had with Guardian #26 and included in part "... [The guardian] shared that [Patient #5] stated he saw two girls kiss on the unit and he kissed a girl. [Patient #5] also shared with his mother that some females on the unit wanted to "teach him how to finger a girl"... When asked when this was able to happen, Patient #5 stated that when "the slow kid" had an outburst the staff had to respond which provided them with the opportunity. He also shared that there was a code that the patients came up with. This was a knocking system which would alert their peers if staff were coming ... [Guardian #26] did not request a call back but stated [Guardian #26] did not want this to happen with other children...".

4. During an interview on 8/12/21 at 12:32 PM, Chief Executive Officer (CEO) verified the documentation created by the Nurse Manager should have triggered the hospital staff to identify the complaint was a grievance and the hospital staff should have followed the hospital's grieveance process.

5. During an interview on 8/18/21 at 1:07 PM, Guardian #26 revealed they called the hospital on 8/2/21, shortly after the hospital staff discharged Patient #5 home. Guardian #26 expressed concern to the hospital staff that Patient #5 reports of sexual activity during Patient #5's admission in the child and adolescent unit. Patient #5 reported that Patient #5 saw 2 pediatric female patients kissing, Patient #5 touched a female patient's breast for the first time during the hospitalization, and the other pediatric patients wanted to teach Patient #5 "how to finger a girl's vagina the proper way." Guardian #26 expressed concerns regarding the nursing supervision at the hospital and wondered how many other pediatric patients engaged in inappropriate sexual activity in the inpatient child and pediatric unit. Guardian #26 was especially dismayed about the situation as "the hospital is supposed to be a safe setting." Guardian #26 voiced frustration as the hospital staff informed Guardian #26 at the time of the call that a hospital staff member would follow up with Guardian #26 the following day, but the hospital staff failed to follow up with Guardian #26 over a week later.

6. During an interview on 8/17/21 at 2:45 PM, The CNO acknowledged the Nurse Manager informed the CNO about Guardian #26's concerns that pediatric patients engaged in sexual activity on the child and adolescent unit. The CNO forgot that Guardian #26 notified the hospital about their concerns regarding pediatric patients engaging in inappropriate sexual behavior in the child and adolescent unit. Since the CNO forgot about Guardian #26's concerns, and did not recognize that Guardian #26's concerns rose to the level of a grievance, the CNO failed to investigate Guardian #26's concerns. The CNO also failed to follow up with Guardian #26 in regards to the outcome of the grievance. The CNO also revealed that if a complaint comes in after the patient's discharge, the CNO does not investigate the concerns.

Based on document review and staff interview, the Hospital's governing board failed to approve the patient grievance process. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure of the governing board to approve the patient grievance process could potentially result in the governing board not being responsible for the effective operation of the grievance process.

Findings include:

1. Review of the policy "Managing Patient Grievances," dated last approved 1/2021, revealed in part, "... The Board of Governors designates, in writing, a Sub-Committee on Patient Rights within the Performance Improvement Committee as the committee responsible for the effectiveness operation of the grievance process and for the review and resolution of grievances...."

2. Review of the Board of Governors Meeting minutes, dated 2/8/21, revealed the governing board approved the Quality Assurance/Performance Plan.

3. Review of the Quality Assurance & Performance Improvement Plan revealed the plan lacked documentation the Governing Board designated a Sub-Committee on Patient Rights, within the Performance Improvement Committee, as the committee responsible for the effectiveness operation of the grievance process and for the review and resolution of grievances.

4. During an interview on 8/18/21 at 4:50 PM, the Chief Executive Officer acknowledged the Board of Governors approved the Quality Assurance/Performance Plan that lacked documentation the Governing Board designated a Sub-Committee on Patient Rights, within the Performance Improvement Committee, as the committee responsible for the effectiveness operation of the grievance process and for the review and resolution of grievances..

Based on document review and staff interviews, hospital administrative staff failed to provide and/or maintain documentation of the written notice provided to the patient/patient's guardian of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in 6 of 9 grievances reviewed. Failure to provide the written notice that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation could potentially result in hospital staff failing to address identified concerns regarding patient care, potentially resulting in life altering/threatening situations for the patient. The hospital administrative staff identified 38 patients upon entrance.


Findings include:

1. Review of the policy "Managing Patient Grievances," approved 1/2021, revealed in part, "...The grievance and problem resolution/follow up shall be documented...documentation shall include: date and time grievance initiated, name of person voicing the grievance/how to contact, name of grievance, date and time that grievance was initiated, pertinent investigation information, resolution of grievance/follow up, signature of person addressing grievance, date and time of resolution, date and time patient/resident or family notified...the grievance will be logged into the Grievance Log...".

The policy lacked a clear process for the maintenance of the written notice provided in response to patient/family grievances.

2. Review of the "Greivances" log revealed 9 grievances received between March 7, 2021 and August 5, 2021. The log showed a letter had been written and provided to 6 of 9 patients but the hospital failed to maintain a copy of the letter to demonstrate communication of the required components.

3. During an interview on 8/16/21 at 10:10 AM, Patient Advocate T revealed he assumed the duties of the Patient Advocate on 8/9/21. Patient Advocate T acknowledged the Grievance Manual he received, which contained the greivance log and grievance documentaion, failed to contain a copy of the written notice provided to each complainant.

4. During an interview on 8/12/21 at 12:32 PM, Chief Executive Officer acknowledged the written notices, provided to 6 of 9 complainants, were missing from the grievance manual.

I. Based on document review and staff interview, the Hospital administrative staff failed to ensure 2 of 7 new employees received a child and dependent adult abuse registry background check (Chief Nursing Officer and Mental Health Technician E) prior to initially starting to work at the hospital. Administrative staff identified approximately 50 new staff hired in the past 5 weeks. Failure to conduct child and dependent adult abuse registry background checks could potentially result in the Hospital staff placing patients at risk for becoming victims of abuse from a new employee, as the hospital staff could not guarantee the new staff member did not have a record of child or dependent adult abuse.

Findings include:

1. Review of a Hospital policy titled "Employment Background Screening", approved on 2/2021, revealed in part "... All applicants for whom a conditional job offer has been made will have a background investigation consisting of ... Sexual offenders and predator registry search ...".

2. Review of the Chief Nursing Officer's personnel file revealed a hire date of 4/1/21. A document titled "Single Contact License and Background Check (SING)," dated 4/7/21, revealed the results of criminal and sex offender registry check but failed to show verification of a child or dependent adult abuse registry check.

3. Review of Mental Health Technician E's personnel file revealed a hire date of 4/12/21. A document titled "Single Contact License and Background Check (SING)," dated 4/8/21, revealed the results of criminal and sex offender registry check but failed to show verification of a child or dependent adult abuse registry check.

4. During an interview on 8/18/21, at 10:05 AM, the Corporate Human Resources Director acknowledged a child and dependent adult abuse registry check should have been conducted and the personnel file lacked documentation to show the results of a child and dependent adult abuse registry check.

The Corporate Human Resources Director confirmed the Hospital did not obtain a child and dependent adult abuse background check for the Chief Nursing Officer and Mental Health Technician E, prior to them beginning work.





II. Based on document review and staff interview, the Hospital administrative staff failed to ensure further criminal background research identified no criminal history prior to beginning work for 2 of 7 new employees selected for review (Registered Nurse A and Registered Nurse B). Administrative staff identified approximately 50 new staff hired in the past 5 weeks. Failure to ensure a potential employee does not have a criminal background, could potentially result in the Hospital staff placing patients at risk for becoming victims of criminal activity from a new employee.

Findings include:

1. Review of a Hospital policy titled "Employment Background Screening", approved on 2/2021, revealed in part "... All applicants for whom a conditional job offer has been made will have a background investigation consisting of ... criminal history search ...".

2. Review of Registered Nurse (RN) A's personnel file revealed a hire date of 6/7/21. A document titled "Single Contact License and Background Check (SING)," dated 6/2/21, revealed further research required by the Department of Criminal Investigation (DCI). RN A's personnel file lacked documentation of further research to determine if the employee had a criminal background which would exclude her employment by the facility.

3. Review of Registered Nurse (RN) B's personnel file revealed a hire date of 6/28/21. A document titled "Single Contact License and Background Check (SING)," dated 6/15/21, revealed further research required by the Department of Criminal Investigation (DCI). RN B's personnel file lacked documentation of further research to determine if the employee had a criminal background which would exclude her employment by the facility.

4. During an interview on 8/18/21, at 10:05 AM, the Corporate Human Resources Director acknowledged RN A's and RN B's criminal background check revealed the need for further research. The personnel files lacked documentation to show the results of further criminal background research had been conducted by the Department of Criminal Investigation.

The Corporate Human Resources Director confirmed the Hospital staff did not obtain the results of further research of a criminal background prior for RN A and RN B, prior to beginning work.





III. Based on document review and staff interview, the Hospital administrative staff failed to ensure and 1 of 7 new employees selected for review, with a criminal background, received an Iowa Department of Human Services (DHS) clearance to work (Mental Health Technician D). Administrative staff identified approximately 50 new staff hired in the past 5 weeks. Failure to ensure the Department of Human Services reviewed and cleared a new employee, with a history of criminal convictions, could potentially result in the Hospital staff placing patients at risk for becoming victims of criminal activity from a new employee.

Findings include:

1. Review of a Hospital policy titled "Employment Background Screening", approved on 2/2021, revealed in part "... All applicants for whom a conditional job offer has been made will have a background investigation consisting of ... criminal history search ...".

2. Review of Mental Health Technician (MHT) D's personnel file revealed a hire date of 2/8/21. A document, in the personnel file, titled "Iowa Record Check Request", dated 2/1/21, revealed the Department of Criminal Investiagions (DCI) identified a criminal record for MHT D and provided a report which contained further details on the criminal conviction. The personnel file lacked evidence DHS staff evaluated and cleared MHT D to work at the Hospital.

3. During an interview on 8/18/21, the Corporate Human Resources Director acknowledged MHT D showed a criminal background and the files lacked evidence the DHS staff performed an evaluation to determine if MHT D could work at the Hospital. She reported the DHS clearance should have been obtained prior to MHT D beginning work but had been missed.

The Corporate Human Resources Director confirmed the Hospital did not obtain an evaluation by DHS prior to MHT D beginning work.

Based on document review and staff interview, the Hospital's administrative staff failed to inform each patient of their visitation rights, including any clinical restriction or limitation on such rights, and the reasons for the clinical restriction or limitation for the inpatient area. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment.

Findings include:

1. Review of the policy "Visitation," dated 2/2021, revealed that the policy failed to address that patients shall have the right, subject to their consent, to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

2. Review of the undated patient handout "Patient Rights and Responsibilities," revealed the patient handout lacked information to inform patients of their right to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

3. During an interview on 8/19/21 at 8:30 AM, the Chief Executive Officer verified the Visitation Policy and the Patient Rights and Responsibilities patient handout lacked information to inform patients of their right to receive the visitors they designate, including but not limited to: a spouse, support person, domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny such consent at any time.

Based on document review and staff interviews, the hospital administrative staff failed to:

1. Ensure the hospital wide performance improvement program set priorities for the quality improvement program to include patient care data collection to monitor the effectiveness, safety, and quality of patient care. Please refer to A-273.

2. Ensure the hospital wide performance improvement program developed indicators that allowed identification of high risk, problem prone areas that affect health outcomes, patient safety, and quality of care. Please refer to A-283.

3. Ensure the hospital wide performance improvement program included the identification, tracking, and investigation of patients' inappropriate behaviors including suicide gestures/attempts, self-harm behaviors, and sexual patient encounters. Please refer to A-286.

4. Ensure the hospital wide performance improvement program included all services offered at the hospital. Please refer to A-308.

The cumulative effect of the systemic failure and deficient practices resulted in the hospital's inability to effectively carry out the responsibilities of the hospital to ensure patients received appropriate care and treatment in a safe setting and ensure quality health care provided to patients. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey.

Based on document review and staff interview, the hospital's administrative staff failed to set priorities for the quality improvement program to include patient care data collection to monitor the effectiveness, safety, and quality of patient care. The Hospital staff failed to include data collection to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure to set priorities for the Quality Improvement Program that affect health outcomes, patient safety, and quality of care resulted in the hospital staff failing to collect data for the purpose of improving patient care.

Findings include:

1. Review of the Quality Assurance & Performance Improvement Plan, approved by the Board of Governors 2/8/21, revealed in part, "...The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care, patient safety, and organization functions. Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether or not problems are suspected...."

2. Review of the Quality/Performance Committee Meeting minutes dated 3/25/21, 4/21/21, 5/26/21, 6/16/21, and 7/21/21, lacked evidence the hospital staff performed data collection to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation.

The hospital staff did not track quality improvement measures related to health outcomes, patient safety, or the quality of patient care.

3. During an interview on 8/19/21 at 8:40 AM, the Chief Executive Officer acknowledged the lack of data collection to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation.

Based on document review and staff interview, the hospital's administrative staff failed to develop indicators that allowed identification of high risk, problem prone areas that affect health outcomes, patient safety, and quality of care. The hospital staff failed to develop indicators to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation.. The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure to develop indicators to identify high risk problem prone areas resulted in the hospital staff failing to monitor and take corrective actions for the purpose of improving patient care and safety.

Findings include:

1. Review of the Quality Assurance & Performance Improvement Plan, approved by the Board of Governors 2/8/21, revealed in part, "...The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care, patient safety, and organization functions...."

2. Review of the Quality/Performance Committee Meeting minutes, dated 3/25/21, 4/21/21, 5/26/21, 6/16/21, and 7/21/21, revealed the meeting minutes lacked evidence of indicators to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation.

3. During an interview on 8/19/21 at 8:40 AM, the Chief Executive Officer acknowledged the lack of indicators to monitor the accuracy of patient medical record documentation, monitor patient safety including, but not limited to, nursing supervision of patients for patient observation levels, patient precautions carried out as ordered, incident reports related to patient events, and review patient treatment plans for required documentation.

Based on document review and staff interviews, the Hospital's administrative staff failed to ensure the quality program included the identification, tracking, and investigation of patients' inappropriate behaviors including suicide gestures/attempts, self-harm behaviors, and sexual patient encounters for 6 of 6 open patient medical records reviewed (Patient #1, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7) and 4 of 4 closed patient medical records (Patient #9, Pateint #12, Patient #24, and Patient #25). The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure of the hospital staff to identify, track, and investigate patients' inappropriate behaviors including suicide gestures/attempts, self-harm behaviors, and sexual patient encounters resulted in the hospital staff failing to monitor and take corrective actions for the purpose of improving patient care and patient safety.

Findings include:

1. Review of the "Quality Assurance & Performance Improvement Plan," approved by the Board of Governors 2/8/2021, revealed in part, "The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care, patient safety, and organization functions ... Organization-wide QAPI activities include utilization management, management of information, infection control, medication use, safety, risk management, and quality control activities ... PI Measure Categories ... Risk Events. Data on all types of risk events trended over time."

2. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences...."

3. Review of the policy "Healthcare Peer Review (HPR) Occurrence Reporting System," approved 2/2021, revealed in part, "...A HPR form is completed when an unusual event with potentially harmful outcome occurs which is not consistent with the routine care of a patient and/or the desired operation of the facility...Responsibility. The Risk Manager will submit summary reports to the Board of Governors, which may include incidents, trends/patterns of events and summaries of evidence and recommended/accomplished corrective actions.

4. The quality program failed to include the patient adverse events, documented on incident reports, that Patient #25 sustained self-inflicted injuries on 4/10/21, 4/17/21, and 4/20/21.

Review of the Quality/Performance Committee Meeting minutes, dated 5/26/21, revealed in part "Reports: Risk Management. April data showed a fall rate/1000 days of 3.88...All other indicators reported zero occurrences...." Documentation lacked evidence the patient's self-inflicted injuries were included as part of the quality program.


5. The quality program failed to include the patient adverse events, documented on incident reports, that Patient #12 sustained self-inflicted injuries on 6/5/21, 6/7/21, and 6/23/21; Patient #12 attempted suicide on 6/13/21; and Patient #24 sustained a self-inflicted injury on 6/23/21.

Review of the Quality/Performance Committee Meeting minutes, dated 7/21/21, revealed in part, "Reports: Risk Management. June data 2 falls...All other indicators reported zero occurrences...." Documentation lacked evidence the patient's self-inflicted injuries were included as part of the quality program.


6. During an interview on 8/3/21 at 3:35 PM, the CNO acknowledged there was a patient event the evening of 8/2/21 where 3 patients (Patient #3, Patient #10, and Patient #11) on the children/adolescent unit had barricaded themselves in a patient room and refused to come out. The CNO reported there was not an incident report completed and no investigation occurred of the event. The CNO revealed the event was over by the time the CNO arrived at the hospital after the nursing staff notified the CNO of the incident.

7. During an interview on 8/4/21 at 8:45 AM, the CNO indicated there was an incident related to Patient #4, with suicidal and homicidal ideation, accessing a knife in the kitchen on 7/23/21. The CNO provided documentation dated 8/3/21 with a review of the incident and training completed. The CNO acknowledged the CNO typed up the hospital's investigation on 8/3/21, after the surveyors asked for the hospital's investigation of the incident.

8. Patient #1 made suicide attempts/gestures on 7/4/21, 7/5/21, 7/9/21, 7/11/21, 7/21/21, and 8/2/21.

9. During an interview on 8/5/21 at 8:35 AM, the CNO provided documentation dated 7/4/21, 7/5/21, 7/9/21, and 8/2/21, regarding investigations related to Patient #1, with suicidal ideation, who made suicide attempts/gestures on those dates. The CNO acknowledged the CNO typed up the hospital's investigation on 8/3/21, after the surveyors asked for the hospital's investigation of the incident.

During an interview on 8/9/21 at 10:20 AM, the CNO acknowledged the hospital failed to complete an investigation related to Patient #1's suicide attempt in the bathroom on 7/11/21.


10. Review of Patient #1's medical record revealed Patient #1 made a suicide attempt in the bathroom on 7/22/21. Review of documentation lacked evidence the hospital staff filled out an incident report of the event and lacked evidence of a hospital investigation of the event.

11. During an interview on 8/9/21 at 2:20 PM, the CNO provided documentation completed on 8/9/21 of a sexual encounter that occurred between Patient #1 and Patient #9 on 7/21/21. Documentation on the incident report completed by the CNO on 8/9/21 revealed "No further investigation required". The CNO was aware of the event at the time of the incident. On 8/5/21 at 11:30 AM, the CNO was previously aware of the incident, verified the hospital staff did not complete an incident report until the CNO created an incident report on 8/9/21, and the CNO failed to investigate the sexual encounter between Patient #1 and Patient #9.

12. On 8/12/21 the Nurse Manager provided documentation of a patient event the Nurse Manager became aware of following a telephone call on 8/2/21 from Guardian #26, after Patient #5 was discharged. The Nurse Manager revealed upon review of a video recording of an incident that occurred on 7/30/21 at 7:54 PM, Patient #3, Patient #5, Patient #6, Patient #7, and Patient #10 were observed to engage in sexual behaviors while left unattended in the nourishment room. The Nurse Manager completed an incident report on the occurrence on 8/12/21 (13 days after the incident) with no further documentation of an investigation.

13. During an interview on 8/19/21 at 11:45 AM, the Chief Executive Officer acknowledged the Board of Governors do not receive any information regarding incident reports. The hospital staff did not track quality improvement measures related to health outcomes, patient safety, or the quality of patient care.

Based on document review and staff interview, the Hospital's administrative staff failed to develop, evaluate, and implement an effective Quality Improvement Program to evaluate and improve the quality and appropriateness of patient care and to improve quality on a continuous basis including all services, offered at the hospital for 2 of 10 departments (Plant Operations and Housekeeping). The Hospital's administrative staff identified a census of 38 patients at the beginning of the survey. Failure to create and implement an effective quality improvement program that included involvement of all of the Hospital's departments to improve quality on a continuous basis could potentially result in the hospital staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved departments.

Findings include:

1. Review of the Quality Assurance & Performance Improvement Plan, approved by the Board of Governors on 2/8/21, revealed in part, "... The Governing Body of Clive Behavioral Health has the ultimate responsibility and authority to establish, maintain and support an effective QAPI program. The Governing Body assures that the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. The Governing Body receives and acts upon recommendations regarding quality assessment and improvement activities ... All departments, services and clinical programs participate in the QAPI program...."

2. Review of the Quality/Performance Committee Meeting minutes, dated 3/25/21, 4/21/21, 5/26/21, 6/16/21, and 7/21/21, revealed the meeting minutes lacked evidence of department reports for Plant Operations and Housekeeping.

3. Review of the Board of Governors Meeting minutes, dated 2/8/21, 2/19/21, 4/21/21, and 7/7/21, revealed the meeting minutes lacked evidence of department reports for Plant Operations and Housekeeping.

4. During an interview on 8/19/21 at 11:45 AM, the Chief Executive Officer acknowledged the quality department reports lacked evidence of department reports for Plant Operations and Housekeeping.

I. Based on document review, staff interviews, and video surveillance the hospital administrative staff failed to:

1. Ensure the nursing staff provided adequate supervision and oversight of patient activities on the child and adolescent unit. Please refer to A-0385.

2. Ensure the nursing staff provided adequate supervision, assessment, and evaluation of care to patients on the adult units. Please refer to A-0385.

3. Ensure the hospital had adequate numbers of nurising staff members to provided adequate supervision and oversight of patient activities on the child and adolescent unit. Please refer to A-0392.

4. Ensure the hospital had adequate numbers of nursing staff members to provide 1:1 observation (1 staff person to 1 patient), as ordered by the physician. Please refer to A-0392.

5. Ensure the hospital had adequate numbers of nursing staff members to provide patients adequate supervision, assessment, and evaluation of care received. Please refer to A-0392.


The cumulative effect of these failures and deficient practices resulted in the hospital's inability to provide adequate patient care and supervision for children, adolescents, and adults, which resulted in adolescents engaging in inappropriate sexual behaviors, and could potentially result in self harm, harm to others and death to the patient. The hospital administrative staff identified a census of 38 patients on entrance.



II. During the investigation of complaints 98835-C and 99111-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patient's at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23). The hospital failed to provide adequate nursing supervision and oversight of patient activities.

1. The administrative staff failed to initially develop and implement a corrective action plan to ensure nursing staff provided adequate supervision, assessment, evaluation of patient care, and 1:1 observation.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 8/11/2021 at 3:08 PM. The hospital staff took action and removed the immediacy of the situation prior to the survey team exiting the complaint investigation when the hospital administrative staff took the following steps:

a. Conducted a review of all patients at risk for suicide, ensuring suicide precautions were present and all contraband (items not allowed) had been removed from the patent environment.

b. Modified the "Contraband/Search Guidelines" policy and added additional items.

c. Revised the policy "Patient Observation Rounds/Level of Observation" to ensure following any incident of self-harm or harm to others, the patient is placed on 1:1 observation, the physician is contacted, and identified the process to ensure the patient received the 1:1 observation/ level of care required, as ordered by the physician.

d. Revised the policy related to nursing assessments to include requirements for reassessment after any incident of self-harm, significant behavioral issue, or change in condition, and to update the patient's treatment plan.

e. Provided reeducation of all staff on each of the policy changes prior to their next scheduled shift.

f. Provided education to all RN's, House Supervisors, and Administrators on Call (AOC) on the modified policies, staffing expectations, and reassessment/documentation expectations.

g. The hospital administrative staff implemented a system to monitor compliance. The CEO, CNO, and senior management team are responsible for monitoring the ongoing compliance.

The following Condition level deficiency remained for the Condition of Participation for Nursing Services (42 CFR 482.23).

I. Based on document review, staff interviews, and video surveillance review the Hospital administrative staff failed to ensure the hospital had adequate numbers of nursing staff to provide adequate supervision and oversight of patient activities on 1 of 1 child and adolescent unit. Failure to ensure the hospital had adequate numbers of nursing staff to provide providing adequate supervision for child and adolescent patients resulted in the nursing staff failing to identify and prevent patients from engaging in inappropriate sexual behavior and could potentially also result in self harm, harm to others and death to the patient. The Hospital Administrative Staff identified a current census of 9 patients on the child and adolescent unit at the beginning of the survey.

Findings include:

1. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "to ensure ... appropriate numbers and qualifications of nursing staff are available at all times for the care of patients ... [the] Chief Nursing Officer [CNO] is responsible for development and ongoing review of staffing requirements based on numbers of patients, population served, [patient] acuity ... designed to comply with all applicable regulatory standards ..." "[The CNO will develop a] staffing plan for each unit [that] establishes the minimal staffing levels ..." "[The] special needs of patients related to their medical and psychiatric care ... always primary factors [in the staffing plan] ..." "[The] CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety..."

2. During an interview on 8/11/21 at 10:30 AM, Registered Nurse (RN) K reported she generally works the 7:00 AM to 7:00 PM shift and most of the time there is only 1 RN and 1 Mental Health Technician (MHT) on each floor and finds it difficult to provide adequate supervision and oversight to the patients and ensure patient safety. When there is only 1 RN and 1 MHT on the unit, and the RN is occupied passing medications, the 1 MHT is left to supervise the other patients. RN K acknowledged when a patient requests to use the restroom or take a shower, the MHT would leave the remainder of patients unsupervised.

RN K reported she took a phone call from Guardian #26, reporting concerns that Patient #5 informed Guardian #26 that there was potentially sexual activity between patients during Patient #5's admission to the child and adolescent unit. RN K forwarded Guardian #26's call to the Nurse Manager. The nursing staff discovered Patient #7's journal included accounts of sexual activity involving Patient #2, Patient #5, Patient #6 and Patient #7. Patient #7's journal indicated the pediatric patients engaged in sexual activity in the playground and nourishment room.


3. During an interview on 8/11/21 at 2:52 PM, the Nurse Manager acknowledged they received a phone call with Guardian #26 informing the Nurse Manager that Patient #5 had reported to Guardian #26 sexual activity occurred between the pediatric patients during Patient #5's admission.

4. During an interview on 8/18/21 at 1:07 PM, Guardian #26 revealed they called the hospital on 8/2/21, shortly after the hospital staff discharged Patient #5 home. Guardian #26 expressed concern to the hospital staff that Patient #5 reported sexual activity during Patient #5's admission in the child and adolescent unit. Patient #5 reported that Patient #5 saw 2 pediatric female patients kissing, Patient #5 touched a female patient's breast for the first time during the hospitalization, and the other pediatric patients wanted to teach Patient #5 "how to finger a girl's vagina the proper way." Guardian #26 expressed concerns regarding the nursing supervision at the hospital and wondered how many other pediatric patients engaged in inappropriate sexual activity in the inpatient pediatric unit. Guardian #26 was especially dismayed about the situation as "the hospital is supposed to be a safe setting."

5. Review of an untitled document, provided by the Nurse Manager, dated 8/12/21, revealed a summary of a phone call she had with Guardian #26 and included in part "... [The guardian] shared that [Patient #5] stated [Patient #5] saw two girls kiss on the unit and [Patient #5] kissed a girl. [Patient #5] also shared ... that some females on the unit wanted to "teach [Patient #5] how to finger a girl"... When asked when this was able to happen, Patient #5 stated that when "the slow kid" had an outburst the staff had to respond which provided them with the opportunity. [Patient #5] shared that there was a code that the patients came up with. This was a knocking system which would alert their peers if staff were coming ...".

6. During an interview on 8/17/21 at 12:00 PM, the Nurse Manager reported they received loose journal pages the day before Patient #7 discharged from the hospital and the Nurse Manager received Patient #7's full journal the day Patient #7 discharged from the hospital. Patient #7's journal included descriptions of sexual activity between pediatric patients.

The Nurse Manager contacted Patient #7 for additional information about the situations included in Patient #7's journal. Patient #7 indicated the pediatric patients found opportunities to engage in sexual activity with other pediatric patients when the MHT was occupied with other tasks. The Nurse Manager indicated that the nursing staff was not sure if the nursing staff could separate and provide sufficient nursing supervision to the pediatric patients identified in Patient #7's journal.

7. Review of Patient #7's journal revealed the journal included Patient #7's description of engaging in sexual activity with other pediatric patients and contained descriptions of sexual activities occurring between other pediatric patients on the child and adolescent unit. Patient #7 referenced in their journal that sexual activity between pediatric patients occurred in the pediatric patients' rooms, on the supervised courtyard swing set, in the nourishment room, and under a table in the child and adolescent unit.

8. Review of video surveillance on 7/30/21, beginning at approximately 7:45 PM, in the large activity room and nourishment room, revealed 5 patients present in the large activity room when MHT P unlocked the nourishment room door (located inside the large activity room). Patient #10 and Patient #6 entered the nourishment room and Patient #10 began getting a beverage while Patient #6 stood in the doorway. At 7:54:51 PM, MHT P left the doorway, leaving Patient #10 and Patient #6 in the nourishment room. As MHT P left the activity room, Patient #3 ran to the nourishment room and all 3 patients remained in the nourishment room with the door closed. Immediately, Patient #3 and Patient #6 began kissing and Patient #10 remained in the corner of the room watching Patient #3 and Patient #6 kiss. At 7:55:52 PM, Patient #3 opened the nourishment room door and looked out, allowing Patient #5 and Patient #7 to enter the nourishment room and join Patient #3, Patient #6, and Patient #10. Once the door closed, Patient #6 and Patient #7 began kissing and Patient #3 and Patient #5 began kissing. Patient #6 attempted to kiss Patient #5, but Patient #5 pulled away. Patient #3 opened the nourishment room door at approximately 7:56:14 PM and looked out at the same time Registered Nurse (RN) R entered the large activity room. MHT P entered behind RN R and returned to the nourishment room doorway at 7:56:14 PM.

9. During an interview on 8/18/21 at 4:13 PM, MHT P revealed they normally work on the 3:00 PM to 11:00 PM shift. The hospital's administration normally only schedules 1 MHT on the evening shift. During MHT P's shift, around 7:30 PM, MHT P unlocks the nourishment room so the patients can get an evening snack. MHT P supervises the patients in the activity room and nourishment room. However, if a patient requires assistance in another part of the inpatient behavioral health unit, MHT P must leave the patients in the nutrition room unsupervised, so MHT P can attend to the needs of the other patient.

10. During an interview on 8/17/21 at 2:45 PM, the Chief Nursing Officer (CNO) indicated they received information about Patient #7's journal and Guardian #26's phone call around the time the staff became aware of the sexual activity between the pediatric patients, but failed to take any action or perform any investigation at the time. After the on-site survey team brought the sexual activity between pediatric patients to the CNO's attention, the CNO began reviewing video footage from the hospital's cameras in the child and adolescent unit. The CNO discovered the video footage from 7/30/21 of the pediatric patients engaging in sexual activity in the nourishment room. The CNO acknowledged the nursing staff left the pediatric patients unsupervised in the nourishment room, which allowed the pediatric patients to engage in sexual activity in the child and adolescent inpatient behavioral health unit.













II. Based on document review and staff interviews, the hospital administrative staff failed to ensure the hospital had sufficient nursing staff to provide 1:1 observation (1 staff person to 1 patient), as ordered by the physician, in 1 of 13 open medical records reviewed (Patient #1) and 1 of 1 closed medical records (Patient #12) reviewed. Failure to ensure the hospital had sufficient numbers of nursing staff to dedicate 1 staff person to 1 patient, as required on 1:1 observation, could potentially result in the staff failing to sufficiently monitor patients at a very high risk of attempting suicide, homicide, or engaging in other inappropriate behavior, potentially resulting in a patient successfully committing suicide, homicide, or inappropriate sexual contact with another patient, all without the staff's knowledge. At the time of entrance, the hospital's administrative staff identified the hospital had a census of 38 patients, and 10 of the 38 patients had physician ordered suicide precaution monitoring.

Findings include:

1. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "to ensure ... appropriate numbers and qualifications of nursing staff are available at all times for the care of patients ... [the] Chief Nursing Officer [CNO] is responsible for development and ongoing review of staffing requirements based on numbers of patients, population served, [patient] acuity ... designed to comply with all applicable regulatory standards ..." "[The CNO will develop a] staffing plan for each unit [that] establishes the minimal staffing levels ..." "[The] special needs of patients related to their medical and psychiatric care ... always primary factors [in the staffing plan] ..." "[The] CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety..." "Factors which affect the need to alter staffing levels include ... Patients placed on 1 to 1 monitoring".

2. Review of the policy "Patient Care Shift Assignments," approved 2/2021, revealed in part, "[A] Charge Nurse will be assigned to each nursing unit by the Nursing Supervisor." "[The] charge nurse shall plan, supervise and evaluate the nursing care of each patient ..." "[The] Nurse Manager, [and] Nursing Supervisor ... will monitor ... [patient] care demands ... [and] will make the necessary staffing adjustments for the next shift." "[D]uties and responsibilities ... [may be] delegated to other RN's [and Mental Health Technicians] ... [however, ultimate] responsibility and accountability for patient care remains with the Charge Nurse ..." "[E]xamples of tasks/duties that may be assigned [to other staff members include] ... Timed checks or constant observation (rounds, 1:1, behavior precautions) ... [and] Safety rounds/Reporting Safety issues ..."

3. During an interview on 8/11/21 at 3:25 PM, the Nurse Manager revealed the hospital currently has 5 people employed as Nursing Supervisors. Of the 5 staff members, 1 Nursing Supervisor will start in September 2021 (the month following the survey), 2 Nursing Supervisors are not working due to them being on medical leave, 1 Nursing Supervisor was off work on medical leave and would not start working as a Nursing Supervisor until 8/27/21 (over a week after the survey exit), and 1 Nursing Supervisor would only work on weekends. The hospital currently lacked any Nursing Supervisors to work during the week.


4. Review of the policy "Patient Observation Rounds/Level of Observation" effective 2/2021, revealed in part, "[Patients are] routinely observed in compliance with physician orders ..." "staff members are assigned by the Registered Nurse [on] their responsibilities in monitoring the patient ..." "RN may NOT discontinue precautions or decrease the level of observation, e.g. change from 1:1 to [every] 15 minute [observation rounding] ..." "[Any] decrease in level of observation requires a physician order ..." "staff will complete the Patient Observation Sheet as the observations are made..." A specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times ..." "continuous observation remaining within one arm's length of the patient will continue when the patient is in shower, changing clothes or using bathroom ..." "[Each] RN will perform at least 6 oversight rounds over a 24 hour period and sign off on the [every] 15 minute Patient Observation Sheet ..."

5. Review of Patient #1's open medical record revealed Psychiatrist D admitted Patient #1 on 6/28/21 at 3:45 PM and placed Patient #1 on Suicide Precautions and Elopement Risk Precautions. Psychiatrist D ordered the staff to observe Patient #1 every 15 minutes. On 7/11/21 at 2:00 PM, Psychiatrist D increased Patient #1's level of observation to 1:1 continuous observation through 7/13/21 at 12:10 PM, following Patient #1 attempting to kill themselves in the hospital's locked inpatient mental health unit on 7/11/21.

Patient #1's "Observation Record Inpatient" for 7/11/21 lacked documentation that informed the staff they should check Patient #1 every 15 minutes prior to Patient #1's suicide attempt and the increased supervision (1:1 observation) the staff should provide to Patient #1 following their suicide attempt as ordered by Psychiatrist D.

Patient #1's "Observation Record Inpatient" for 7/12/21 lacked documentation that informed the staff about the expected observation level for Patient #1, including that the staff should provide 1:1 observation to Patient #1, as ordered by Psychiatrist D. Additionally, on 7/12/21, RN I completed only 1 of the 3 required oversight rounds during the 7:00 PM to 7:00 AM shift.


6. Review of documentation staff rounding sheets during the timeframe Psychiatrist D ordered the staff to provide 1:1 observation to Patient #1 (7/11/21 at 2:00 PM through 7/13/21 at 12:10 PM) revealed the same Mental Health Technician (MHT H) documented they performed every 15 minute safety checks on 7 additional patients (Patient #17, Patient #18, Patient #19, Patient #20, Patient #21, Patient #22, and Patient #23) hospitalized on the same inpatient psychiatric unit as Patient #1 (indicating the nursing staff failed to provide Patient #1 with 1:1 observation with a staff member arm's length away from Patient #1).


7. Review of rounding sheets for the inpatient psychiatric Adult Unit CLU4, on 7/13/21 between 12:02 AM and 2:46 AM, revealed that MHT H documented they performed every 15 minute observation checks for 8 patients in 8 separate rooms. MHT H documented each patient was either asleep or laying down/sitting in their room at the time MHT H observed the patient. The documentation revealed that MHT H did not maintain 1:1 observation of Patient #1 and stay within 1 arm's length of Patient #1 during the time Psychiatrist D ordered 1:1 observation for Patient #1.

Review of the "Observation Record Inpatient" for patients on the Adult Unit CLU4 revealed the following:

a. Patient #1's "Observation Record Inpatient," for 7/13/21, while Patient #1 was on 1:1 observation, revealed MHT H documented Patient #1 was in their room (#225 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, and 2:45 AM.

b. Patient #17's "Observation Record Inpatient," for 7/13/21, while Patient #17 required observation every 15 minutes, revealed MHT H documented Patient #17 was in their room (#220) at 12:02 AM, 12:15 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

c. Patient #18's "Observation Record Inpatient," for 7/13/21, while Patient #18 required observation every 15 minutes, revealed MHT H documented Patient #18 was in their room (#223 A), at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

d. Patient #19's "Observation Record Inpatient," for 7/13/21, while Patient #19 required observation every 15 minutes, revealed MHT H documented Patient #19 was in their room (#222 B) at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

e. Patient #20's "Observation Record Inpatient," for 7/13/21, while Patient #20 required observation every 15 minutes, revealed MHT H documented Patient #20 was in their room (#228 B) at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

f. Patient #21's "Observation Record Inpatient," for 7/13/21, while Patient #21 required observation every 15 minutes, revealed MHT H documented Patient #21 was in their room (#227 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

g. Patient #22's "Observation Record Inpatient," for 7/13/21, while Patient #22 required observation every 15 minutes, revealed MHT H documented Patient #22 was in their room (#224 B) at 12:02 AM, 12:15 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

h. Patient #23's "Observation Record Inpatient," for 7/13/21, while Patient #23 required observation every 15 minutes, revealed MHT H documented Patient #23 was in their room (#226 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.


8. Review of rounding sheets for the inpatient psychiatric Adult Unit CLU4, on 7/13/21 at 7:31 AM through 8:01 AM, revealed that MHT D documented they performed every 15 minute observation checks for 8 patients (7 of the patients located in the dining room on the first floor and 1 patient (Patient #23) remaining in their room on the second floor of the hospital). The documentation revealed that MHT H did not maintain 1:1 observation of Patient #1 and stay within 1 arm's length of Patient #1 during the time Psychiatrist D ordered 1:1 observation for Patient #1.

Review of the "Observation Record Inpatient" for patients on the Adult Unit CLU4 revealed the following:

a. Patient #1's "Observation Record Inpatient," for 7/13/21, while Patient #1 was on 1:1 observation, revealed MHT D documented Patient #1 was in the dining room a at 7:31 AM, 7:46 AM, and 8:01 AM.

b. Patient #17's "Observation Record Inpatient," for 7/13/21, while Patient #17 required observation every 15 minutes, revealed MHT D documented Patient #17 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM,

c. Patient #18's "Observation Record Inpatient," for 7/13/21, while Patient #18 required observation every 15 minutes, revealed MHT D documented Patient #18 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

d. Patient #19's "Observation Record Inpatient," for 7/13/21, while Patient #19 required observation every 15 minutes, revealed MHT D documented Patient #19 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

e. Patient #20's "Observation Record Inpatient," for 7/13/21, while Patient #20 required observation every 15 minutes, revealed MHT D documented Patient #20 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

f. Patient #21's "Observation Record Inpatient," for 7/13/21, while Patient #21 required observation every 15 minutes, revealed MHT D documented Patient #21 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

g. Patient #22's "Observation Record Inpatient," for 7/13/21, while Patient #22 required observation every 15 minutes, revealed MHT D documented Patient #22 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

h. Patient #23's "Observation Record Inpatient," for 7/13/21, while Patient #23 required observation every 15 minutes, revealed MHT D documented Patient #23 was in their patient room (#226, on a different floor than the dining room) at 7:31 AM, 7:46 AM, and 8:01 AM.


9. Review of Patient #12's closed medical record revealed Psychiatrist D admitted Patient #12 on 6/2/21 at 9:56 PM and placed the patient on Suicide Precautions and Elopement Risk, Level of Observation every 15 Minutes. On 6/6/21 at 6:00 PM, Psychiatrist D increased Patient # 12's level of observation to 1:1 observation continuous through 6/8/21 at 8:03 AM, following Patient #12's self-report of increased anxiety and suicidal ideation. On 6/6/21 at 11:00 PM, Psychiatrist D placed an order to stop 1:1 observation at 10:46 PM (14 minutes prior to the order for 1:1 observation). RN O documented in Daily Nursing Progress notes that 1:1 observation was initiated on 6/6/21 at 6:00 PM and RN N documented Patient #12 remained on 1:1 observation for their safety. On 6/7/21 at 2:30 PM, RN L documented "Patient asked Rec[reation] Therapist if [they were] going to be [on] 1:1 [supervision]. Patient was aware and said something to the Rec[reation] therapist about [the hospital] not having enough staff [to provide] 1:1 [supervision to Patient #12]." Patient #12's "Observation Record Inpatient" for 6/6/21 lacked documentation of the date, time, and change in level of observation.


10. Documentation review of Patient # 12's every 15 minute observations during the time frame Psychiatrist D ordered 1:1 Observation, 6/6/21 at 6:00 PM through 6/6/21 at 10:46 PM, and documentation review on 4 additional patients (Patient #13, Patient #14, Patient #15, and Patient #16) hospitalized on the same unit (the only psychiatric unit open in June 2021) revealed the hospital failed to provide 1:1 Observation.

On 6/6/21 at 6:00 PM through 8:15 PM Adult Unit, MHT P and MHT Q provided observation checks for 5 patients located in various locations of the adult psychiatric unit. MHT P and MHT Q had not maintained 1:1 observation and stayed within 1 arm's length of Patient #12.

Review of the "Observation Record Inpatient" documents revealed the following:

a. Patient #12's "Observation Record Inpatient," revealed on 6/6/21, that Patient #12 required 1:1 observation, revealed MHT P documented Patient #12 was in the activity yard at 6:00 PM (on a different floor than the inpatient unit); Patient #12 was in the Quiet Activity Room at 6:15 PM, 7:15 PM, 7:30 PM, and 7:45 PM; and the noisy activity room at 6:31 PM. MHT Q documented that Patient #12 was in the bathroom at 6:46 PM and 7:00 PM; in the quiet activity room at 8:00 PM; and the noisy activity room at 8:15 PM.

b. Patient #13's "Observation Record Inpatient," revealed on 6/6/21, that Patient #13 required observation every 15 minutes, revealed MHT P documented Patient #13 was in the noisy activity room at 6:00 PM (despite MHT P documenting they observed patients in the dining room on a separate floor at the same time), 6:15 PM, 6:31 PM, 7:15 PM, 7:30 PM, and in Patient #13's room at 7:45 PM. MHT Q documented Patient #13 was in the noisy activity room at 6:45 PM and 8:00 PM; and Patient #13 was in an unidentified location at 7:00 PM and 8:15 PM.

c. Patient #14's "Observation Record Inpatient," revealed on 6/6/21, that Patient #14 required observation every 15 minutes, revealed that MHT P documented Patient #14 was in the dining room (on a separate floor from the inpatient unit) at 6:00 PM; in Patient #14's room at 6:15 PM, 6:31 PM, 7:15 PM, 7:30 PM, and 7:45 PM. MHT Q documented Patient #14 was in Patient #14's room at 6:45 PM and 7:00 PM; in the noisy activity room at 8:00 PM, and in the group therapy room at 8:15 PM.

d. Patient #15's "Observation Record Inpatient," revealed on 6/6/21, that Patient #15 required observation every 15 minutes, revealed that MHT P documented Patient #15 was in the dining room (on a separate floor from the inpatient unit) at 6:00 PM; in the noisy activity room at 6:15 PM, 6:31 PM, 7:15 PM, and 7:30 PM; and in Patient #15's room at 7:45 PM. MHT Q documented Patient #15 was in the noisy activity room at 6:45 PM and 7:00 PM; and in Patient #15's room at 8:00 PM.

e. Patient #16's "Observation Record Inpatient," revealed on 6/6/21, that Patient #16 required observation every 15 minutes, revealed that MHT P documented Patient #16 was at the Medication Window at 6:00 PM; in the quiet activity room at 6:15 PM and 8:31 PM; and in the noisy activity room at 7:15 PM, 7:30 PM, and 7:45 PM. MHT Q documented Patient #16 was in the unit hallway at 6:45 PM; in the noisy activity room at 7:00 PM and 8:15 PM; in the quiet activity room at 8:00 PM; and in the noisy activity room at 8:15 PM.



11. During an interview on 8/11/21 at 2:40 PM, MHT P indicated that if a patient was on 1:1 observation, a nursing staff member must be within arm's reach of the patient at all times, even if the patient is taking a shower or using the bathroom. Frequently, MHT P is the only MHT assigned to their unit and is very difficult to provide the ordered observation level to patients.

12. During an interview on 8/11/21 at 2:00 PM, MHT D verbalized their understanding that 1:1 observation means that the staff member is "attached at the hip" with that patient.

13. During an interview on 8/16/2021 at 2:13 PM, RN G revealed Patient #1 attempted to kill themselves on 7/23/21. Psychiatrist F was present on the inpatient unit at the time Patient #1 attempted to kill themselves. Following Patient #1's suicide attempt, Psychiatrist F ordered the nursing staff to provide Patient #1 with 1:1 observation, and documented their order on the communication white board in the nursing station. A short time later, the CNO walked up to the communication white board, erased the 1:1 observation note Psychiatrist F wrote, and the CNO wrote in "line of sight" for Patient #1's observation level. When Psychiatrist F discovered the CNO erased Psychiatrist F's note indicating Patient #1 required 1:1 observation, Psychiatrist F returned to the nursing station, erased "line of sight," rewrote "1:1 observation," initialed the note, and documented the date/time.


14. During an interview on 8/16/2021 at 11:12 AM, Psychiatrist F revealed they had concerns about the staffing in the inpatient psychiatric nursing units. On prior occasions, when patients needed 1:1 observation, Psychiatrist F wanted to order 1:1 observation for the patients, but the nursing staff informed Psychiatrist F they could not provide patients with 1:1 observation due to the low staffing levels.

In the case of Patient #1, Psychiatrist F placed an order for the nursing staff to provide Patient #1 with 1:1 observation in Patient #1's medical record and also documented the order on the communication white board in the nursing station. Later, the nursing staff informed Psychiatrist F that the CNO erased Psychiatrist F's order for 1:1 observation from the communication white board. Psychiatrist F returned to the nursing station and discovered Psychiatrist F's order for 1:1 observation on Patient #1 was missing. Psychiatrist F rewrote the order for 1:1 observation, initialed the order, and dated/timed the note. Psychiatrist F also checked to verify the nursing staff had not discontinued Psychiatrist F's order for 1:1 observation in Patient #1's medical record.





III. Based on document review, staff interviews, and review of video footage, the Hospital administrative staff failed to ensure the hospital had an adequate number of nursing staff members to perform the 15 Minute Safety Checks for 1 of 13 open patient records reviewed (Patient #1). Failure to ensure the hospital had an adequte number of nursing staff members to provide adequate supervision and perform regular safety checks provided the patients an opportunity to engage in inappropriate behavior, such as potential sexual contact with another patient, attempting suicide, self-harm, or assault without staff detection. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "to ensure ... appropriate numbers and qualifications of nursing staff are available at all times for the care of patients ... [the] Chief Nursing Officer [CNO] is responsible for development and ongoing review of staffing requirements based on numbers of patients, population served, [patient] acuity ... designed to comply with all applicable regulatory standards ..." "[The CNO will develop a] staffing plan for each unit [that] establishes the minimal staffing levels ..." "[The] special needs of patients related to their medical and psychiatric care ... always primary factors [in the staffing plan] ..." "[The] CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety..." "Factors which affect the need to alter staffing levels include ... Patients placed on 1 to 1 monitoring".

2. Review of the policy "Patient Observation Rounds/Level of Observation" effective 2/2021, revealed in part, "[Patients are] routinely observed in compliance with physician orders ..." "staff members are assigned by the Registered Nurse [on] their responsibilities in monitoring the patient ..." "staff will complete the Patient Observation Sheet as the observations are made..." "A specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times ..." "continuous observation remaining within one arm's length of the patient will continue when the patient is in shower, changing clothes or using bathroom ..." "[Each] RN will perform at least 6 oversight rounds over a 24 hour period and sign off on the [every] 15 minute Patient Observation Sheet ...".

3. Review of video footage from 7/5/21 at 11:05 PM of Mental Health Tech (MHT) J rounding on Unit 4 (adult hall) revealed MHT J did not visually assess each patient in their room to verify patients' whereabouts and any risky behaviors patients may engage in. MHT J walked towards Patient #1's door and stopped before reaching Patient #1's doorway. MHT J failed to observe that Patient #1 had taken a garment, tied a knot in one end, placed the knot at the top of the door, closed the door, and tied the other end of the garment around Patient #1's neck in an attempt by Patient #1 to kill themself. RN J walked into Patient #1's room approximately 1 minute later and discovered that Patient #1 was attempting to hang themself.

4. During an interview on 8/9/21 at 9:30 AM, the CEO reviewed the video footage of Patient #1 attempting to hang themself in the inpatient behavior health unit. The CEO verified when the MHTs perform patient rounding, the MHT should visually observe the patient and ensure the patient was not attempting to kill themself in the room.

5. Review of Patient #1's open medical record revealed Psychiatrist D admitted Patient #1 on 6/28/21 at 3:45 PM and placed Patient #1 on Suicide Precautions and Elopement Risk Precautions. Psychiatrist D ordered the staff to observe Patient #1 every 15 minutes. On 7/11/21 at 2:00 PM, Psychiatrist D increased Patient #1's level of observation to 1:1 continuous observation through 7/13/21 at 12:10 PM, following Patient #1 attempting to kill themself in the hospital's locked inpatient mental health unit on 7/11/21.

Further review of the staff's documentation of their every 15 minute safety observations revealed during Patient #1's hospitalization that on 63 separate occasions, the hospital staff failed to perform the required visualization of Patient #1 (potentially allowing Patient #1 to engage in suicide attempts as the staff members did not provide adequate supervision).

6. During an interview on 8/11/21 at 1:11 PM, RN S revealed that if a MHT became dedicated to a single patient, such as providing 1:1 continuous observation, RN S had to provide all of the patient cares, including performing

I. Based on document review, staff interviews, and review of video footage, the Hospital's administrative staff failed to ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for 1 of 13 reviewed open patient records (Patient #1) and 1 of 2 reviewed closed patient records (Patient #12). Failure to provide adequate nursing supervision, assessment, and evaluation of care resulted in the nursing staff failing to provide adequate patient care, which could result in a very serious self-harm, harm to others or death for the patient. The Hospital's administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "to ensure ... appropriate numbers and qualifications of nursing staff are available at all times for the care of patients ...required to provide safe, quality patient care ...".

2. During an interview on 8/11/21 at 3:25 PM, the Nurse Manager revealed the hospital currently has 5 people employed as Nursing Supervisors. Of the 5 staff members, 1 Nursing Supervisor will start in September 2021 (the month following the survey), 2 Nursing Supervisors are not working due to them being on medical leave, 1 Nursing Supervisor was off work on medical leave and would not start working as a Nursing Supervisor until 8/27/21 (over a week after the survey exit), and 1 Nursing Supervisor would only work on weekends. The hospital currently lacked any Nursing Supervisors to work during the week.

3. Review of the policy "Patient Care Shift Assignments," approved 2/2021, revealed in part, "[A] Charge Nurse will be assigned to each nursing unit by the Nursing Supervisor." "[The] charge nurse shall plan, supervise and evaluate the nursing care of each patient ..." "[The] Nurse Manager, [and] Nursing Supervisor ... will monitor ... [patient] care demands ... [and] will make the necessary staffing adjustments for the next shift." "[D]uties and responsibilities ... [may be] delegated to other RN's [and Mental Health Technicians] ... [however, ultimate] responsibility and accountability for patient care remains with the Charge Nurse ..." "[E]xamples of tasks/duties that may be assigned [to other staff members include] ... Timed checks or constant observation (rounds, 1:1, behavior precautions) ... [and] Safety rounds/Reporting Safety issues..."

4. Review of video footage from 7/5/21 at 11:05 PM of Mental Health Tech (MHT) J rounding on Unit 4 (adult hall) revealed MHT J did not visually assess each patient in their room to verify patients' whereabouts and any risky behaviors patients may engage in. MHT J walked towards Patient #1's door and stopped before reaching Patient #1's doorway. MHT J failed to observe that Patient #1 had taken a garment, tied a knot in one end, placed the knot at the top of the door, closed the door, and tied the other end of the garment around Patient #1's neck in an attempt by Patient #1 to kill themself. RN J walked into Patient #1's room approximately 1 minute later and discovered that Patient #1 was attempting to hang themself.


5. During an interview on 8/9/21 at 9:30 AM, the CEO reviewed the video footage of Patient #1 attempting to hang themself in the inpatient behavior health unit. The CEO verified when the MHTs perform patient rounding, the MHT should visually observe the patient and ensure the patient was not attempting to kill themself in the room.

6. Review of Patient #1's open medical record revealed Psychiatrist D admitted Patient #1 on 6/28/21 at 3:45 PM and placed Patient #1 on Suicide Precautions and Elopement Risk Precautions. Psychiatrist D ordered the staff to observe Patient #1 every 15 minutes. On 7/11/21 at 2:00 PM, Psychiatrist D increased Patient #1's level of observation to 1:1 continuous observation through 7/13/21 at 12:10 PM, following Patient #1 attempting to kill themself in the hospital's locked inpatient mental health unit on 7/11/21.

Further review of the staff's documentation of their every 15 minute safety observations revealed during Patient #1's hospitalization that on 63 separate occasions, the hospital staff failed to perform the required visualization of Patient #1 (potentially allowing Patient #1 to engage in suicide attempts as the staff members did not provide adequate supervision).


7. Review of the policy "Patient Observation Rounds/Level of Observation," effective 2/2021, revealed in part, "[Patients are] routinely observed in compliance with physician orders ..." "staff members are assigned by the Registered Nurse [on] their responsibilities in monitoring the patient ..." "staff will complete the Patient Observation Sheet as the observations are made..." "A specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times ..." "continuous observation remaining within one arm's length of the patient will continue when the patient is in shower, changing clothes or using bathroom ..." "[Each] RN will perform at least 6 oversight rounds over a 24 hour period and sign off on the [every] 15 minute Patient Observation Sheet ..."

8. Review of Patient #12's closed medical record revealed Psychiatrist D admitted Patient #12 on 6/2/21 at 9:56 PM and placed the patient on Suicide Precautions and Elopement Risk, Level of Observation every 15 Minutes. On 6/6/21 at 6:00 PM, Psychiatrist D increased Patient # 12's level of observation to 1:1 observation continuous through 6/8/21 at 8:03 AM, following Patient #12's self-report of increased anxiety and suicidal ideation. On 6/6/21 at 11:00 PM, Psychiatrist D placed an order to stop 1:1 observation at 10:46 PM (14 minutes prior to the order). RN O documented in Daily Nursing Progress notes that 1:1 observation was initiated on 6/6/21 at 6:00 PM and RN N documented Patient #12 remained on 1:1 observation for their safety. On 6/7/21 at 2:30 PM, RN L documented "Patient asked Rec[reation] Therapist if [they were] going to be [on] 1:1 [supervision]. Patient was aware and said something to the Rec[reation] therapist about [the hospital] not having enough staff [to provide] 1:1 [supervision to Patient #12]." Patient #12's "Observation Record Inpatient" for 6/6/21 lacked documentation of the date, time, and change in level of observation.

9. During an interview on 8/11/21 at 1:11 PM, RN S revealed that if a MHT became dedicated to a single patient, such as providing 1:1 continuous observation, RN S had to provide all of the patient cares, including performing the safety checks, providing medical care to the patients, medication administration, and nursing supervision.

10. During an interview on 8/16/21 at 11:12 AM, Psychiatrist F revealed they had concerns about the staffing in the inpatient psychiatric nursing units. Psychiatrist F had previously attempted to order that the nursing staff observe a patient on 1:1 continuous observation. However, when Psychiatrist F informed the nursing staff of the need for 1:1 continuous observation, the nursing staff indicated they could not provide 1:1 observation for the patient, as the nursing staff did not have sufficient staff to dedicate a staff member to 1:1 observation on a specific patient, as there would not be a staff member available to supervise the patients without 1:1 observation.

11. During an interview on 8/17/21 at 2:45 PM, the CNO revealed they would normally inform the Staffing Coordinator about the need for additional staffing if a patient required 1:1 observation or if a unit required additional staffing. However, the Staffing Coordinator was on medical leave starting on 7/28/21. Thus, without the Staffing Coordinator, the CNO was responsible for ensuring the nursing units had sufficient staffing to ensure adequate patient care. The CNO acknowledged they failed to ensure the nursing units had sufficient staffing to provide nursing supervision when patients required 1:1 observation.




30076


II. Based on document review, staff interviews, and video surveillance review, the Hospital administrative staff failed to ensure the nursing staff provided adequate supervision and oversight of patient activities on 1 of 1 child and adolescent unit. Failure to provide adequate supervision for child and adolescent patients resulted in the nursing staff failing to identify and prevent patients from engaging in inappropriate sexual behavior and could potentially also result in self harm, harm to others and death to the patient. The Hospital Administrative Staff identified a current census of 9 patients on the child and adolescent unit at the beginning of the survey.

Findings include:

1. Review of the policy "Patient Observation Rounds/Level of Observation" effective 2/2021, revealed in part, "... Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... "

2. During an interview on 8/11/21 at 10:30 AM, Registered Nurse (RN) K reported they generally work the 7:00 AM to 7:00 PM shift and most of the time there is only 1 RN and 1 Mental Health Technician (MHT) on each floor and finds it difficult to provide adequate supervision and oversight to the patients. When there is only 1 RN and 1 MHT, and the RN is occupied passing medications, the 1 MHT is left to supervise the other patients. RN K acknowledged when a patient requests to use the restroom or take a shower, the MHT would leave the remainder of patients unsupervised.

RN K reported they took a phone call from Guardian #26, reporting concerns that Patient #5 informed Guardian #26 that there was potentially sexual activity between patients during Patient #5's admission. RN K forwarded Guardian #26's call to the Nurse Manager. The nursing staff discovered Patient #7's journal included accounts of sexual activity involving Patient #2, Patient #5, Patient #6 and Patient #7. Patient #7's journal indicated the pediatric patients engaged in sexual activity in the playground and nourishment room.


3. During an interview on 8/11/21 at 2:52 PM, the Nurse Manager acknowledged they received a phone call with Guardian #26 informing the Nurse Manager that Patient #5 had reported to Guardian #26 about sexual activity between the pediatric patients during Patient #5's admission.


4. During an interview on 8/18/21 at 1:07 PM, Guardian #26 revealed they called the hospital on 8/2/21, shortly after the hospital staff discharged Patient #5 home. Guardian #26 expressed concern to the hospital staff that Patient #5 reported sexual activity occurred during Patient #5's admission in the child and adolescent unit. Patient #5 reported that Patient #5 saw 2 pediatric female patients kissing, Patient #5 touched a female patient's breast for the first time during the hospitalization, and the other pediatric patients wanted to teach Patient #5 "how to finger a girl's vagina the proper way." Guardian #26 expressed concerns regarding the nursing supervision at the hospital and wondered how many other pediatric patients engaged in inappropriate sexual activity in the inpatient pediatric unit. Guardian #26 was especially dismayed about the situation as "the hospital is supposed to be a safe setting."

5. Review of an untitled document, provided by the Nurse Manager, dated 8/12/21, revealed a summary of a phone call the Nurse Manager had with Guardian #26 and included in part "... [The guardian] shared that [Patient #5] stated [Patient #5] saw two girls kiss on the unit and [Patient #5] kissed a girl. [Patient #5] also shared ... that some females on the unit wanted to "teach [Patient #5] how to finger a girl"... When asked when this was able to happen, Patient #5 stated that when "the slow kid" had an outburst the staff had to respond which provided them with the opportunity. [Patient #5] shared that there was a code that the patients came up with. This was a knocking system which would alert their peers if staff were coming ...".

6. During an interview on 8/17/21 at 12:00 PM, the Nurse Manager reported they received loose journal pages the day before Patient #7 discharged from the hospital and the Nurse Manager received Patient #7's full journal the day Patient #7 discharged from the hospital. Patient #7's journal included descriptions of sexual activity between pediatric patients.

The Nurse Manager contacted Patient #7 for additional information about the situations included in Patient #7's journal. Patient #7 indicated the pediatric patients found opportunities to engage in sexual activity with other pediatric patients when the MHT was occupied with other tasks. The Nurse Manager indicated that the nursing staff was not sure if the nursing staff could separate the pediatric patients involved in the sexual activities and provide sufficient nursing supervision to the pediatric patients identified in Patient #7's journal.


7. Review of Patient #7's journal revealed the journal included Patient #7's description of engaging in sexual activity with other pediatric patients and contained descriptions of sexual activities occurring between other pediatric patients on the child and adolescent unit. Patient #7 referenced in their journal that sexual activity between pediatric patients occurred in the pediatric patients' rooms, on the supervised courtyard swing set, in the nourishment room, and under a table in the child and adolescent unit.

8. Review of video surveillance on 7/30/21, beginning at approximately 7:45 PM, in the large activity room and nourishment room, revealed 5 patients present in the large activity room when MHT P unlocked the nourishment room door (located inside the large activity room). Patient #10 and Patient #6 entered the nourishment room and Patient #10 began getting a beverage while Patient #6 stood in the doorway. At 7:54:51 PM, MHT P left the doorway, leaving Patient #10 and Patient #6 in the nourishment room. As MHT P left the activity room, Patient #3 ran to the nourishment room and all 3 patients remained in the nourishment room with the door closed. Immediately, Patient #3 and Patient #6 began kissing, and Patient #10 remained in the corner of the room watching Patient #3 and Patient #6 kiss. At 7:55:52 PM, Patient #3 opened the nourishment room door and looked out, allowing Patient #5 and Patient #7 to enter the nourishment room and join Patient #3, Patient #6, and Patient #10. Once the door closed, Patient #6 and Patient #7 began kissing, and Patient #3 and Patient #5 began kissing. Patient #6 attempted to kiss Patient #5, but Patient #5 pulled away. Patient #3 opened the nourishment room door at approximately 7:56:14 PM and looked out at the same time Registered Nurse (RN) R entered the large activity room. MHT P entered behind RN R and returned to the nourishment room doorway at 7:56:14 PM.

9. During an interview on 8/18/21 at 4:13 PM, MHT P revealed they normally work on the 3:00 PM to 11:00 PM shift. The hospital's administration normally only schedules 1 MHT on the evening shift. During MHT P's shift, around 7:30 PM, MHT P unlocks the nourishment room so the patients can get an evening snack. MHT P supervises the patients in the activity room and nourishment room. However, if a patient requires assistance in another part of the inpatient behavioral health unit, MHT P must leave the patients in the nutrition room unsupervised, so MHT P can attend to the needs of the other patient.

10. During an interview on 8/17/21 at 2:45 PM, the Chief Nursing Officer (CNO) indicated they received information about Patient #7's journal and Guardian #26's phone call around the time the staff became aware of the sexual activity between the pediatric patients, but failed to take any action or perform any investigation at the time. After the on-site survey team brought the sexual activity between pediatric patients to the CNO's attention, the CNO began reviewing video footage from the hospital's cameras in the child and adolescent unit. The CNO discovered the video footage from 7/30/21 of the pediatric patients engaging in sexual activity in the nourishment room. The CNO acknowledged the nursing staff left the pediatric patients unsupervised in the nourishment room, which allowed the pediatric patients to engage in sexual activity in the child and adolescent inpatient behavioral health unit.

44424


Based on document review and staff interview, the Hospital's administrative staff failed to:

1. Ensure the nursing staff followed the hospital's medical record policy to ensure the completed accurate documentation of safety precautions, ordered by the physician. Please refer to A-0438.

2. Ensure the nursing staff completed accurate documentation of observation level, ordered by the physician. Please refer to A-0438.

3. Ensure the nursing staff provide accurate documentation of the nursing oversight of the patient safety rounds. Please refer to A-0438.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure the nursing staff provided accurate documentation of safety precautions, observation level and nursing oversight to each patient needs in a safe environment. The lack of regular safety checks (approximately every 15 minutes per policy), 1:1 observations, and nursing oversight created a situation which could result in patients attempting to engage in suicide or sexual contact with another patient, without the staff's knowledge. The Hospital's administrative staff identified a patient census of 38 on entrance.

I. Based on document review and staff interviews, the Hospital administrative staff failed to ensure nursing staff completed accurate documentation of the safety precautions, ordered by the physician, on the Observation Record Inpatient document for 10 of 13 open patient records reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #10, and Patient #11) and 1 of 2 closed patient records reviewed (Patient #9). Failure to ensure the nursing staff kept accurate documentation of patient safety precautions could potentially result in a lack of understanding a patient's behavior and failure to implement appropriate oversight and interventions, and result in self-harm, harm to others or death for the patient. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Patient Observation Rounds/Level of Observation", approved 2/2021, revealed in part, " ... Patients are routinely observed in compliance with physician orders ... Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... The orders will identify a specific precaution, each with a specified level of observation for: suicide, assault/homicide, elopement, sexual familiarity (aggressor/at risk), falls, medically compromised, and other ... Staff assigned to complete patient observation rounds will ... Reflect changes in individual patient precaution levels, room changes, new admissions and/or discharges as they occur ... Observe each patient a minimum of every 15 minutes and according to precaution level ... ".

2. Review of the policy "Assessment of Suicide and Suicide Risk Management", approved 3/2021, revealed in part, "... Suicide Precautions are to be clearly indicated on the assignment sheet and patient specific rounds sheets ...".

3. Review of the policy "Assault/Homicide Prevention and Precautions", approved 2/2021, revealed in part "... To provide a plan for monitoring aggressive/violent individuals via Assault Precautions and Homicide Precautions, identifying early warning signs, and implementing interventions to prevent assault/homicide incidents ... Staff assigned to monitor individuals on Assault or Homicide Precautions shall be vigilant for identification of assaultive behaviors ... Nursing/Unit Staff ... Communicates the precautions and level of monitoring to the unit staff and ensures the Observation Rounds Sheet accurately reflect the precaution type and level of monitoring ...".

4. During an interview on 8/5/21 at 11:20 AM, the Chief Nursing Officer (CNO) reported the admission staff initiated the process of precaution documentation by placing all new patients on the appropriate precautions, which are ordered by the physician. The precautions are recorded on the Observation Record Inpatient document which should be filled out by the overnight Registered Nurse (RN), based on the orders placed in the Electronic Medical Record (EMR). The CNO acknowledged the Observation Record Inpatient form serves as a communication tool, and if not filled out, staff would not know what precautions patients were on.

5. During an interview on 8/12/21 at 8:05 AM, RN A reported at midnight, the PM nurse is responsible to check the EMR for the current precaution orders and ensure they are documented correctly on the Daily Nursing Assessment Progress Note and Observation Record Inpatient document and if the precautions orders change during the day, the nurse would reflect the changes on both documents.

6. During an interview on 8/17/21 at 11:00 AM, the Nurse Manager reported the overnight shift is responsible to initiate the new Observation Record Inpatient documents for each patient and the RN identifies the precautions on the front and back of the document, based on the physician order in the EMR.


7. The open medical record for Patient #1 identified an admission date of 6/28/21 at 3:45 PM. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions starting 6/28/21 at 10:00 PM, elopement precautions discontinued on 8/6/21 at 7:15 AM. Suicide precautions discontinued on 7/1/21 at 6:25 AM, and reordered on 7/4/21 at 2:00 PM discontinued on 8/6/21 at 7:51 AM. Fall precautions ordered 7/8/21 at 6:00 PM, discontinued on 8/6/21 at 7:51 AM. Sexual Aggression precautions ordered on 7/22/21 at 12:00 PM, discontinued on 7/29/21 at 10:08 PM. Sexual victimization risk precautions order 7/29/21 at 11:00 PM, discontinued on 8/6/21 at 7:51 AM.

b. On 7/2/21, 7/3/21, 7/4/21, 7/9/21, 7/14/21, 7/18/21, 7/22/21, 7/23/21, 7/24/21, 7/25/21, 7/26/21, 7/31/21, 8/2/21, 8/3/21, 8/4/21, and 8/5/21, the nursing staff failed to identify the appropriate precautions based on the physician order on the front and the back of the Observation Record Inpatient document, which identifies the specific interventions to use for the patient.


8. The open medical record for Patient #2 identified an admission date of 7/15/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions on 7/15/21 and discontinued suicide precautions on 7/17/21, reordered suicide precautions on 7/30/21, and discontinued suicide precautions on 7/31/21, and reordered suicide precautions on 8/2/21. On 8/9/21 a physician ordered sexual aggression precautions.

b. On 7/21/21, 7/22/21, 7/23/21, 7/26/21, 7/27/21, 7/30/21, 7/31/21, 8/2/21, 8/4/21, 8/5/21, 8/6/21 and 8/9/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


9. The open medical record for Patient #3 identified an admission date of 7/26/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions on 7/26/21 and discontinued suicide precautions on 8/4/21.

b. On 7/27/21 and 7/26/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


10. The open medical record for Patient #4 identified an admission date of 7/19/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions on 7/19/21, discontinued suicide precautions on 8/8/21, and discontinued elopement precautions on 8/9/21. On 7/25/21 a physician ordered suicide/assault precautions.

b. On 7/25/21, 7/26/21, 8/2/21, 8/3/21, and 8/5/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


11. The open medical record for Patient #5 identified an admission date of 7/25/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions on 7/25/21 and discontinued suicide precautions on 8/1/21.

b. On 7/25/21 and 7/27/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


12. The open medical record for Patient #6 identified an admission date of 7/27/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide, elopement and assault/homicide precautions on 7/27/21, and discontinued suicide and assault/homicide precautions on 7/31/21.

b. On 7/30/21, 8/1/21, and 8/2/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


13. The open medical record for Patient #7 identified an admission date of 7/26/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide, sexual victimization and elopement precautions on 7/25/21, and discontinued suicide precautions on 8/1/21.

b. On 7/25/21 and 7/27/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


14. The open medical record for Patient #8 identified an admission date of 7/28/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide precautions on 7/28/21 and discontinued suicide precautions on 8/1/21.

b. On 7/28/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, on the front and the back of the Observation Record Inpatient document, which identifies the specific interventions to use for the patient.


15. The closed medical record for Patient #9 identified an admission date of 7/20/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide, sexual aggression, assault/homicide, and elopement precautions on 7/20/21, and discontinued suicide precautions on 7/25/21. The physician discontinued the sexual aggression, assault/homicide, and elopement precautions on 7/27/21.

b. On 7/20/21, 7/21/21, 7/24/21, 7/25/21, and 7/28/21, the nursing staff failed to identify the appropriate precautions based on the physician order on the front and the back of the document, which identified the specific interventions to use for the patient.


16. The open medical record for Patient #10 identified an admission date of 7/27/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and assault/homicide precautions on 7/27/21 and discontinued suicide precautions on 8/1/21.

b. On 7/27/21, the nursing staff failed to identify the appropriate precautions based on the physician order on the front and the back of the document, which identified the specific interventions to use for the patient.


17. The open medical record for Patient #11 identified an admission date of 7/28/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered elopement precautions on 7/29/21.

b. On 8/7/21, the nursing staff failed to identify the appropriate precautions based on the physician order on the front and the back of the Observation Record Inpatient document, which identified the specific interventions to use for the patient.


18. The Nurse Manager confirmed the overnight shift is responsible to initiate the new Observation Record Inpatient document for each patient and the RN is responsible to ensure the precautions, based on the physician order in the EMR, are correctly identified on the front and back of the Observation Record Inpatient document.





II. Based on document review and staff interviews, the Hospital administrative staff failed to ensure the nursing staff completed accurate documentation of the observation level, ordered by the physician, on the Observation Record Inpatient document for 3 of 13 open patient records reviewed (Patient #1, Patient #4, Patient #11) and 1 of 2 closed patient records reviewed (Patient #9). Failure to ensure the nursing staff kept accurate documentation of patient level of observation could potentially result in a lacking of understanding a patient's behavior and failure to implement appropriate oversight and interventions, and result in self-harm, harm to others or death for the patient. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Patient Observation Rounds/Level of Observation," approved 2/2021, revealed in part, " ... Patients are routinely observed in compliance with physician orders ... Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... The orders will identify a specific precaution, each with a specified level of observation ... [every] 15 Minute Observations ... One-to-One Observation (1:1) ...".

2. During an interview on 8/12/21 at 8:05 AM, RN A reported at midnight each day the overnight nurse is responsible to check the Electronic Medical Record (EMR) for the current precaution and observation level orders and ensure they are documented on the correctly Observation Record Inpatient document and if the precautions orders change during the day, the nurse would reflect the changes on both documents.

3. During an interview on 8/17/21 at 11:00, the Nurse Manager reported the overnight shift is responsible to initiate the new Observation Record Inpatient documents for each patient and the RN identifies the observation level, ordered by the physician in the EMR, on the front of the document. The Nurse Manager confirmed the RN is also responsible to document the observation level on the Daily Nursing Assessment Progress Note.

4. The open medical record for Patient #1 identified an admission date of 6/28/21 at 10:00 PM. Review of the medical record revealed inaccurate documentation of the observation level on the Observation Record Inpatient document as follows:

a. A physician ordered observation level every 15 minute checks on 6/28/21 at 10:00 PM with no discontinuation. 1:1 observation (continuous observation) with 1 staff member to 1 patient) ordered on 7/11/21 at 2:00 PM, discontinued on 7/13/21 at 12:10 PM. 1:1 observation reordered on 7/23/21 at 9:00 AM, discontinued on 7/26/21 at 9:48 AM. Line of sight ordered on 7/26/21 at 10:00 AM, discontinued 8/6/21 at 7:51 AM.

b. On 7/11/21, 7/12/21, 7/14/21, 7/18/21, 7/19/21, 7/27/21, 8/2/21, 8/4/21, 8/5/2, and 8/6/21, the nursing staff failed to identify the appropriate observation level based on the physician order on the front of the document, which identified the specific level of observation for the patient.


5. The open medical record for Patient #4 identified an admission date of 7/19/21. Review of the medical record revealed inaccurate documentation of the observation level on the Observation Record Inpatient document as follows:

a. A physician ordered an observation level of every 15 minutes on 7/19/21.

b. On 7/19/21, 7/26/21, 8/2/21, 8/3/21, 8/5/21, and 8/6/21, the nursing staff failed to identify the appropriate observation level based on the physician order on the front of the document, which identified the specific level of observation for the patient.


6. The closed medical record for Patient #9 identified an admission date of 7/20/21. Review of the medical record revealed inaccurate documentation of the observation level on the Observation Record Inpatient document as follows:

a. A physician ordered an observation level of every 15 minutes on 7/20/21.

b. On 7/20/21, 7/21/21, 7/23/21, and 7/26/21, the nursing staff failed to identify the appropriate observation level based on the physician order on the front of the document, which identified the specific level of observation for the patient.


7. The open medical record for Patient #11 identified an admission date of 7/28/21. Review of the medical record revealed inaccurate documentation of the observation level on the Observation Record Inpatient document as follows:

a. A physician ordered an observation level of every 15 minutes on 7/29/21.

b. On 7/29/21 and 8/7/21, the nursing staff failed to identify the appropriate observation level based on the physician order on the front of the document, which identified the specific level of observation for the patient.


8. The Nurse Manager confirmed the overnight shift is responsible to initiate the new Observation Record Inpatient document for each patient and the RN is responsible to ensure the observation level, ordered by the physician in the EMR, is identified correctly on the Observation Record Inpatient document.





III. Based on document review and staff interviews, the Hospital administrative staff failed to ensure nursing staff completed accurate documentation of the nursing oversight on the Observation Record Inpatient document for 10 of 13 open patient records reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #10, and Patient #11) and 1 of 2 closed patient records reviewed (Patient #9). Failure to ensure the nursing staff kept accurate documentation of nursing oversight of patients could potentially result in a lack of understanding a patient's behavior and failure to implement appropriate oversight and interventions, and result in self-harm, harm to others or death for the patient. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Patient Observation Rounds/Level of Observation" approved 2/2021, revealed in part, " ... Patients are routinely observed in compliance with physician orders ... Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... Registered Nurse (RN) will perform at least 6 oversight rounds reviews evenly distributed over a 24 hour period and sign off on the q15 (every 15) minute Patient Observation Sheet as indicated ...".

2. During an interview on 8/11/21 at 11:32 AM, RN L reported it was difficult to do rounding if you only have 1 RN. RN L acknowledged patient care would come before charting.

3. During an interview on 8/17/21 at 12:00, the Nurse Manager reported the overnight shift is responsible to initiate the new Observation Record Inpatient documents for each patient and the RN identifies the observation level on the front, based on the order in the EMR. The RN is responsible for oversight of patient observation rounds to ensure they are completed, which is required 3 times per shift. The Nurse Manager confirmed the RN verified the oversight by signing at the bottom of the form.

4. The open medical record for Patient #1 identified an admission date of 6/28/21 at 10:00 PM. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 6/29/21, 7/2/21, 7/4/21, 7/6/21, 7/7/21, 7/9/21, 7/10/21, 7/11/21, 7/12/21, 7/13/21, 7/14/21, 7/16/21, 7/19/21, 7/22/21, 7/23/21, 7/24/21, 7/25/21, 7/26/21, 7/27/21, 7/29/21, 7/30/21, 7/31/21, 8/1/21, 8/2/21, 8/3/21, 8/4/21, and 8/5/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


5. The open medical record for Patient #2 identified an admission date of 7/15/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/21/21, 7/22/21, 7/23/21, 7/26/21, 7/30/21, 7/31/21, 8/4/21, 8/5/21 and 8/6/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


6. The open medical record for Patient #3 identified an admission date of 7/26/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/26/21, 7/27/21, 7/27/21, 7/29/21, 7/30/21, 8/1/21, 8/2/21/, 8/4/21, and 8/5/21 nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


7. The open medical record for Patient #4 identified an admission date of 7/19/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/22/21, 7/23/21, 7/24/21, 7/7/25/21, 7/27/21, 7/29/21, 7/30/21, 7/31/21, 8/1/21, 8/3/21, 8/4/21, 8/5/21, 8/7/21, 8/8/21, and 8/9/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


8. The open medical record for Patient #5 identified an admission date of 7/25/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/26/21, 7/27/21, 7/29/21, 7/30/21, 7/30/21, 7/31/21, and 8/1/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


9. The open medical record for Patient #6 identified an admission date of 7/27/21. Review of the medical record revealed the lack of documentation for nursing oversight on the Observation Record Inpatient document as follows:

On 7/29/21, 7/30/21, 7/31/21, and 8/1/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


10. The open medical record for Patient #7 identified an admission date of 7/25/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/25/21, 7/26/21, 7/29/21, 7/30/21, 7/31/21, 8/1/21, 8/2/21, 8/4/21, and 8/5/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


11. The open medical record for Patient #8 identified an admission date of 7/28/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/29/21, 8/1/21, 8/2/21, an 8/3/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


12. The closed medical record for Patient #9 identified an admission date of 7/21/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/23/21, 7/26/21 and 7/28/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


13. The open medical record for Patient #10 identified an admission date of 7/27/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/29/21, 7/30/21, 8/1/21, 8/2/21, 8/3/21 and 8/4/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


14. The open medical record for Patient #11 identified an admission date of 7/28/21. Review of the medical record revealed the lack of documentation for nursing oversight of the patient observation rounds on the Observation Record Inpatient document as follows:

On 7/30/21, 7/31/21, 8/1/21, 8/2/21, 8/4/21, 8/5/21, 8/6/21, and 8/11/21, the nursing staff failed to document appropriate nursing oversight of the patient observation rounds on the Observation Level Inpatient sheet.


15. The Nurse Manager confirmed the overnight shift is responsible to initiate the new Observation Record Inpatient document for each patient and the RN is responsible for oversight of patient observation rounds and confirmed the RN verified the oversight by signing at the bottom of the Observation Record Inpatient document and acknowledged the hospital does not currently audit the Observation Record Inpatient document form completeness and accuracy.





IV. Based on document review and staff interviews, the Hospital administrative staff failed to ensure nursing staff completed accurate documentation of the safety precautions, ordered by the physician, on the Daily Nursing Assessment Progress Note for 10 of 13 open patient records reviewed (Patient #1, Patient #2, Patient#3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #10 and Patient #11) and 1 of 2 closed patient records reviewed (Patient #9). Failure to ensure the nursing staff kept accurate documentation of patient safety precautions could potentially result in a lack of understanding a patient's behavior and failure to implement appropriate oversight and interventions, and result in self-harm, harm to others or death for the patient. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Patient Observation Rounds/Level of Observation", approved 2/2021, revealed in part " ... Patients are routinely observed in compliance with physician orders ... Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... The orders will identify a specific precaution, each with a specified level of observation for: suicide, assault/homicide, elopement, sexual familiarity (aggressor/at risk), falls, medically compromised, and other ... Staff assigned to complete patient observation rounds will ... Reflect changes in individual patient precaution levels, room changes, new admissions and/or discharges as they occur ... Observe each patient a minimum of every 15 minutes and according to precaution level ... ".

2. Review of the policy "Daily Nursing Assessment and Progress Note", approved 2/2021, revealed in part "...Documentation by Nursing staff members shall be thorough, concise, accurate and will reflect the nursing process and the individual patients' response to the goals and interventions outlined in their respective treatment plan ...".

3. During an interview on 8/5/21 at 11:20 AM, the Chief Nursing Officer (CNO) reported the admission staff initiates the process of precaution documentation by placing all new patients on the appropriate precautions, which are ordered by the physician. The precautions are recorded on the Observation Record Inpatient document which should be filled out by the overnight Registered Nurse (RN), based on the orders placed in the Electronic Medical Record (EMR). The CNO acknowledged the Observation Record Inpatient form serves as a communication tool, and if not filled out, staff would not know what precautions patients were on.

4. During an interview on 8/10/21 at 10:30 AM, RN K reported the specific patient precautions are ordered by the physician in the EMR and are to be documented on the Daily Nursing Assessment Progress Note and Observation Record Inpatient document.

5. During an interview on 8/11/21 on 11:32 AM, RN L revealed it was difficult to do documentation if you only have 1 RN. RN L acknowledged patient care would come before charting.

6. During an interview on 8/12/21 at 8:05 AM, RN A reported at midnight, the PM nurse is responsible to check the EMR for the current precaution orders and ensure they are documented on the correctly on the Daily Nursing Assessment Progress Note and Observation Record Inpatient document. If the precautions orders change during the day, the nurse would reflect the changes on both documents.

7. During an interview on 8/17/21 at 12:00, the Nurse Manager reported the overnight shift is responsible to initiate the new Observation Record Inpatient documents for each patient and the RN identified the precautions on the front and back of the document, based on the order in the EMR.

8. The open medical record for Patient #1 identified an admission date of 6/28/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Daily Nursing Assessment Progress Note as follows:

a. A physician ordered suicide and elopement precautions starting 6/28/21 at 10:00 PM, elopement precautions discontinuing on 8/6/21 at 7:15 AM. Suicide precautions discontinued on 7/1/21 at 6:25 AM, reorder was placed on 7/4/21 at 2:00 PM, and discontinued on 8/6/21 at 7:51 AM. Fall precautions ordered 7/8/21 at 6:00 PM, discontinued on 8/6/21 at 7:51 AM. Sexual Aggression precautions ordered on 7/22/21 at 12:00 PM, discontinued on 7/29/21 at 10:08 PM. Sexual victimization risk precautions order 7/29/21 at 11:00 PM, discontinued on 8/6/21 at 7:51 AM.

b. On 7/1/21,7/2/21, 7/8/21, 7/10/21, 7/13/21, 7/14/21, 7/15/21, 7/19/21, 7/22/21, 7/23/21, 7/24/21, 7/29/21, 7/30/21, 8/2/21, and 8/6/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, for both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts.


9. The open medical record for Patient #2 identified an admission date of 7/15/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Daily Nursing Assessment Progress Note as follows:

a. A physician ordered suicide and elopement precautions on 7/15/21, discontinued suicide precautions on 7/17/2, reordered suicide precautions on 7/30/21, discontinued suicide precautions on 7/31/21, and reordered suicide precautions on 8/2/21. On 8/7/21 a physician ordered sexual victimization precautions and on 8/9/21 a physician ordered sexual aggression precautions

b. On 7/15/21, 7/16/21, 7/20/21, 7/23/21, 7/25/21, 7/28/21, 7/29/21, 8/1/21, 8/10/21, and 8/11/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, for both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts.


10. The open medical record for Patient #3 identified an admission date of 7/26/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Daily Nursing Assessment Progress Note as follows:

a. A physician ordered suicide and elopement precautions on 7/26/21 and discontinued suicide precautions on 8/4/21.

b. On 7/31/21, 8/2/21, and 8/3/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, for both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts.


11. The open medical record for Patient #4 identified an admission date of 7/19/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Daily Nursing Assessment Progress Note as follows:

a. A physician ordered suicide and elopement precautions on 7/19/21, discontinued suicide precautions on 8/8/21, and discontinued elopement precautions on 8/9/21.

b. On 7/23/21, 7/7/24, 7/25/21, 7/30/21, and 8/4/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, for both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts.


12. The open medical record for Patient #5 identified an admission date of 7/25/21. Review of the medical record revealed inaccurate documentation of the safety precautions on the Observation Record Inpatient document as follows:

a. A physician ordered suicide and elopement precautions on 7/25/21 and discontinued suicide precautions on 8/1/21.

b. On 7/28/21 and 8/2/21, the nursing staff failed to identify the appropriate precautions, based on the physician order, for both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts.


13. The open medical record for Patient #6 identified an admission date of 7/27/21. Review of t

Based on document review and staff interviews the Hospital Administrative staff failed to ensure patient treatment plans were reviewed and revised based on psychiatric evaluations, a new or significant change in a patient's clinical condition and patient's treatment progress for 7 of 13 open records selected for review (Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #10, and Patient #11) and 1 of 2 closed records selected for review (Patient #9). Failure to develop patient specific goals with target dates, review and revise treatment plans, could potentially lead to the staff failing to measure the patient's progress toward meeting planned goals and delays in treatment adjustments during the patient's admission, which could prolong the patient's stay and impact patient safety upon discharge. The Hospital administrative staff identified a current census of 38 inpatients at the beginning of the survey.

Findings include:

1. Review of the policy "Interdisciplinary Patient Centered Care Planning", approved 2/2021, revealed in part, " ... All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed ... Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... including ... completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline ... The treatment team, including the patient/family representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days ... A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs ... During the treatment plan review, the treatment team will evaluate if goals have been met by established target dates. Once a goal has been resolved, the date will be identified on the treatment plan. ... If the goal has not been met, the team needs to either reevaluate the target date and establish a new one, or re-evaluate the appropriateness of the goal. ... Staff members, upon discharge, shall either document on remaining goals the date if resolved or "ongoing" meaning that the problem has not yet been resolved ... ".

2. Review of Patient #4's open medical record revealed the hospital staff admitted Patient #4 on 7/19/21 and discharged Patient #4 on 8/10/21. The Treatment Plan Problem Sheet, initiated 7/20/21, revealed the hospital staff failed to identify target dates for the goals and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #4's progress on the problems and goals at the time of Patient #4's discharge.

3. Review of Patient #5's open medical record revealed the hospital staff admitted Patient #5 on 7/25/21 and discharged Patient # of 8/2/21. The Treatment Plan Problem Sheet, initiated 7/26/21, revealed the hospital staff identified a target date for the goals, and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #5's progress on the problems and goals at the time of Patient #5's discharge.

4. Review of Patient #6's open medical record revealed the hospital staff admitted Patient #6 on 7/27/21 and discharged Patient #6 of 8/2/21. The Treatment Plan Problem Sheet revealed the hospital staff failed to identify the initiation date and target dates for the goals, and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #6's progress on the problems and goals at the time of Patient #6's discharge.

5. Review of Patient #7's open medical record revealed the hospital staff admitted Patient #7 on 7/25/21 and discharged Patient #7 of 8/6/21. The Treatment Plan Problem Sheet, initiated 7/27/21, revealed the hospital staff identified a target date for the goals, and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #7's progress on the problems and goals at the time of Patient #7's discharge.

6. Review of Patient #8's open medical record revealed the hospital staff admitted Patient #8 on 7/28/21 and discharged Patient #8 of 8/3/21. The medical record failed to include a Treatment Plan Problem Sheet, used to identify short and long term goals and interventions for each appropriate discipline, and the Master Treatment plan failed to address the status of Patient #8's progress on the identified problem at the the time of Patient #8's discharge.

7. Review of Patient #9's closed medical record revealed the hospital staff admitted Patient #9 on 7/20/21 and discharged Patient #9 of 7/28/21. The Treatment Plan Problem Sheet, initiated 7/21/21, revealed the hospital staff identified target dates for the goals, and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #9's progress on the problems and goals at the time of Patient #9's discharge.

8. Review of Patient #10's open medical record revealed the hospital staff admitted Patient #10 on 7/27/21 and discharged Patient #8 of 8/4/21. The medical record failed to include a Treatment Plan Problem Sheet, used to identify short and long term goals and interventions for each appropriate discipline, and the Master Treatment plan failed to address the status of Patient #10's progress on the identified problem at the the time of Patient #10's discharge.

9. Review of Patient #11's open medical record revealed the hospital staff admitted Patient #11 on 7/28/21 and discharged Patient # of 8/11/21. The Treatment Plan Problem Sheet, initiated 7/30/21, revealed the hospital staff identified a target date for the goals, and neither the Master Treatment Plan, nor the Treatment Plan Problem Sheet addressed the status of Patient #11's progress on the problems and goals at the time of Patient #11's discharge.

10. During an interview on 8/09/21 at 12:00 PM, the Director of Social Services reported the Master Treatment Plan is developed with input from the Registered Nurse (RN), Social Worker and Psychiatrist within 72 hours of admission should be reviewed a minimum of every 7 days. The Director of Social Services explained each patient should have a Master Treatment Plan and a Treatment Problem Sheet which are used to identify goals with target dates, for the identified problems and progress toward the goals should be documented at each Master Treatment Plan review and at the time of discharge.

The Direct of Social Services confirmed a Master Treatment Plan and Treatment Problem Sheet should be developed for each patient within 72 hours of admission, include specific goals with target dates, and the patient's progress toward the established goals at the time of discharge.

Based on document review and staff interviews the hospitals staffing failed to ensure the hospital's staffing contained adequate numbers of registered nurses (RN) and mental health technicians (MHT) to monitor patient's placed on 1:1 Observation (1 staff person to 1 patient), as ordered by the physician. Please refer to A-1704.

Failure to specify and dedicate 1 staff person to 1 patient, as required on 1:1 observation, could potentially result in the staff failing to sufficiently monitor patients at a very high risk of attempting suicide, homicide, or engaging in other inappropriate behavior, potentially resulting in a patient successfully committing suicide, homicide, or inappropriate sexual contact with another patient, all without the staff's knowledge. At the time of entrance, the hospital's administrative staff identified the hospital had a census of 38 patients, and 10 of the 38 patients had physician ordered suicide precaution monitoring.

Based on document review and staff interviews, the hospital administrative staff failed to ensure the hospital's staffing contained an adequate numbers of registered nurses (RN) and mental health workers (MHT) to monitor patients placed on 1:1 Observation (1 staff person to 1 patient), as ordered by the physician, in 1 of 13 open medical records reviewed (Patient #1) and in 1 of 2 closed medical records reviewed (Patient #12). Failure to specify and dedicate 1 staff person to 1 patient, as required on 1:1 observation, could potentially result in the staff failing to sufficiently monitor patients at a very high risk of attempting suicide, homicide, or engaging in other inappropriate behavior, potentially resulting in a patient successfully committing suicide, homicide, or inappropriate sexual contact with another patient, all without the staff's knowledge. At the time of entrance, the hospital's administrative staff identified the hospital had a census of 38 patients, and 10 of the 38 patients had physician ordered suicide precaution monitoring.

Findings include:

1. Review of the policy "Appropriate Staffing Levels," approved 2/2021, revealed in part, "to ensure ... appropriate numbers and qualifications of nursing staff are available at all times for the care of patients ... [the] Chief Nursing Officer [CNO] is responsible for development and ongoing review of staffing requirements based on numbers of patients, population served, [patient] acuity ... designed to comply with all applicable regulatory standards ..." "[The CNO will develop a] staffing plan for each unit [that] establishes the minimal staffing levels ..." "[The] special needs of patients related to their medical and psychiatric care ... always primary factors [in the staffing plan] ..." "[The] CNO/delegates are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety..." "Factors which affect the need to alter staffing levels include ... Patients placed on 1 to 1 monitoring".

2. Review of the policy "Patient Care Shift Assignments," approved 2/2021, revealed in part, "[A] Charge Nurse will be assigned to each nursing unit by the Nursing Supervisor." "[The] charge nurse shall plan, supervise and evaluate the nursing care of each patient ..." "[The] Nurse Manager, [and] Nursing Supervisor ... will monitor ... [patient] care demands ... [and] will make the necessary staffing adjustments for the next shift." "[D]uties and responsibilities ... [may be] delegated to other RN's [and Mental Health Technicians] ... [however, ultimate] responsibility and accountability for patient care remains with the Charge Nurse ..." "[E]xamples of tasks/duties that may be assigned [to other staff members include] ... Timed checks or constant observation (rounds, 1:1, behavior precautions) ... [and] Safety rounds/Reporting Safety issues ..."

3. During an interview on 8/11/21 at 3:25 PM, the Nurse Manager revealed the hospital currently has 5 people employed as Nursing Supervisors. Of the 5 staff members, 1 Nursing Supervisor will start in September 2021 (the month following the survey), 2 Nursing Supervisors are not working due to them being on medical leave, 1 Nursing Supervisor was off work on medical leave and would not start working as a Nursing Supervisor until 8/27/21 (over a week after the survey exit), and 1 Nursing Supervisor would only work on weekends. The hospital currently lacked any Nursing Supervisors to work during the week.


4. Review of the policy "Patient Observation Rounds/Level of Observation" effective 2/2021, revealed in part, "[Patients are] routinely observed in compliance with physician orders ..." "staff members are assigned by the Registered Nurse [on] their responsibilities in monitoring the patient ..." "RN may NOT discontinue precautions or decrease the level of observation, e.g. change from 1:1 to [every] 15 minute [observation rounding] ..." "[Any] decrease in level of observation requires a physician order ..." "staff will complete the Patient Observation Sheet as the observations are made..." A specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times ..." "continuous observation remaining within one arm's length of the patient will continue when the patient is in shower, changing clothes or using bathroom ..." "[Each] RN will perform at least 6 oversight rounds over a 24 hour period and sign off on the [every] 15 minute Patient Observation Sheet ..."

5. Review of Patient #1's open medical record revealed Psychiatrist D admitted Patient #1 on 6/28/21 at 3:45 PM and placed Patient #1 on Suicide Precautions and Elopement Risk Precautions. Psychiatrist D ordered the staff to observe Patient #1 every 15 minutes. On 7/11/21 at 2:00 PM, Psychiatrist D increased Patient #1's level of observation to 1:1 continuous observation through 7/13/21 at 12:10 PM, following Patient #1 attempting to kill themselves in the hospital's locked inpatient mental health unit on 7/11/21.

Patient #1's "Observation Record Inpatient" for 7/11/21 lacked documentation that informed the staff they should check Patient #1 every 15 minutes prior to Patient #1's suicide attempt and the increased supervision (1:1 observation) the staff should provide to Patient #1 following their suicide attempt as ordered by Psychiatrist D.

Patient #1's "Observation Record Inpatient" for 7/12/21 lacked documentation that informed the staff about the expected observation level for Patient #1, including that the staff should provide 1:1 observation to Patient #1, as ordered by Psychiatrist D. Additionally, on 7/12/21, RN I completed only 1 of the 3 required oversight rounds during the 7:00 PM to 7:00 AM shift.


6. Review of documentation staff rounding sheets during the timeframe Psychiatrist D ordered the staff to provide 1:1 observation to Patient #1 (7/11/21 at 2:00 PM through 7/13/21 at 12:10 PM) revealed the same Mental Health Technician (MHT H) documented they performed every 15 minute safety checks on 7 additional patients (Patient #17, Patient #18, Patient #19, Patient #20, Patient #21, Patient #22, and Patient #23) hospitalized on the same inpatient psychiatric unit as Patient #1 (indicating the nursing staff failed to provide Patient #1 with 1:1 observation with a staff member arm's length away from Patient #1).


7. Review of rounding sheets for the inpatient psychiatric Adult Unit CLU4, on 7/13/21 between 12:02 AM and 2:46 AM, revealed that MHT H documented they performed every 15 minute observation checks for 8 patients in 8 separate rooms. MHT H documented each patient was either asleep or laying down/sitting in their room at the time MHT H observed the patient. The documentation revealed that MHT H did not maintain 1:1 observation of Patient #1 and stay within 1 arm's length of Patient #1 during the time Psychiatrist D ordered 1:1 observation for Patient #1.

Review of the "Observation Record Inpatient" for patients on the Adult Unit CLU4 revealed the following:

a. Patient #1's "Observation Record Inpatient," for 7/13/21, while Patient #1 was on 1:1 observation, revealed MHT H documented Patient #1 was in their room (#225 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, and 2:45 AM.

b. Patient #17's "Observation Record Inpatient," for 7/13/21, while Patient #17 required observation every 15 minutes, revealed MHT H documented Patient #17 was in their room (#220) at 12:02 AM, 12:15 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

c. Patient #18's "Observation Record Inpatient," for 7/13/21, while Patient #18 required observation every 15 minutes, revealed MHT H documented Patient #18 was in their room (#223 A), at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

d. Patient #19's "Observation Record Inpatient," for 7/13/21, while Patient #19 required observation every 15 minutes, revealed MHT H documented Patient #19 was in their room (#222 B) at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

e. Patient #20's "Observation Record Inpatient," for 7/13/21, while Patient #20 required observation every 15 minutes, revealed MHT H documented Patient #20 was in their room (#228 B) at 12:02 AM, 12:16 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

f. Patient #21's "Observation Record Inpatient," for 7/13/21, while Patient #21 required observation every 15 minutes, revealed MHT H documented Patient #21 was in their room (#227 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

g. Patient #22's "Observation Record Inpatient," for 7/13/21, while Patient #22 required observation every 15 minutes, revealed MHT H documented Patient #22 was in their room (#224 B) at 12:02 AM, 12:15 AM, 12:31 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.

h. Patient #23's "Observation Record Inpatient," for 7/13/21, while Patient #23 required observation every 15 minutes, revealed MHT H documented Patient #23 was in their room (#226 B) at 12:02 AM, 12:16 AM, 12:30 AM, 12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:31 AM, and 2:45 AM.


8. Review of rounding sheets for the inpatient psychiatric Adult Unit CLU4, on 7/13/21 at 7:31 AM through 8:01 AM, revealed that MHT D documented they performed every 15 minute observation checks for 8 patients (7 of the patients located in the dining room on the first floor and 1 patient (Patient #23) remaining in their room on the second floor of the hospital). The documentation revealed that MHT H did not maintain 1:1 observation of Patient #1 and stay within 1 arm's length of Patient #1 during the time Psychiatrist D ordered 1:1 observation for Patient #1.

Review of the "Observation Record Inpatient" for patients on the Adult Unit CLU4 revealed the following:

a. Patient #1's "Observation Record Inpatient," for 7/13/21, while Patient #1 was on 1:1 observation, revealed MHT D documented Patient #1 was in the dining room a at 7:31 AM, 7:46 AM, and 8:01 AM.

b. Patient #17's "Observation Record Inpatient," for 7/13/21, while Patient #17 required observation every 15 minutes, revealed MHT D documented Patient #17 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM,

c. Patient #18's "Observation Record Inpatient," for 7/13/21, while Patient #18 required observation every 15 minutes, revealed MHT D documented Patient #18 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

d. Patient #19's "Observation Record Inpatient," for 7/13/21, while Patient #19 required observation every 15 minutes, revealed MHT D documented Patient #19 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

e. Patient #20's "Observation Record Inpatient," for 7/13/21, while Patient #20 required observation every 15 minutes, revealed MHT D documented Patient #20 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

f. Patient #21's "Observation Record Inpatient," for 7/13/21, while Patient #21 required observation every 15 minutes, revealed MHT D documented Patient #21 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

g. Patient #22's "Observation Record Inpatient," for 7/13/21, while Patient #22 required observation every 15 minutes, revealed MHT D documented Patient #22 was in the dining room at 7:31 AM, 7:46 AM, and 8:01 AM.

h. Patient #23's "Observation Record Inpatient," for 7/13/21, while Patient #23 required observation every 15 minutes, revealed MHT D documented Patient #23 was in their patient room (#226, on a different floor than the dining room) at 7:31 AM, 7:46 AM, and 8:01 AM.


9. Review of Patient #12's closed medical record revealed Psychiatrist D admitted Patient #12 on 6/2/21 at 9:56 PM and placed the patient on Suicide Precautions and Elopement Risk, Level of Observation every 15 Minutes. On 6/6/21 at 6:00 PM, Psychiatrist D increased Patient # 12's level of observation to 1:1 observation continuous through 6/8/21 at 8:03 AM, following Patient #12's self-report of increased anxiety and suicidal ideation. On 6/6/21 at 11:00 PM, Psychiatrist D placed an order to stop 1:1 observation at 10:46 PM (14 minutes prior to the order). RN O documented in Daily Nursing Progress notes that 1:1 observation was initiated on 6/6/21 at 6:00 PM and RN N documented Patient #12 remained on 1:1 observation for their safety. On 6/7/21 at 2:30 PM, RN L documented "Patient asked Rec[reation] Therapist if [they were] going to be [on] 1:1 [supervision]. Patient was aware and said something to the Rec[reation] therapist about [the hospital] not having enough staff [to provide] 1:1 [supervision to Patient #12]." Patient #12's "Observation Record Inpatient" for 6/6/21 lacked documentation of the date, time, and change in level of observation.


10. Documentation review of Patient # 12's every 15 minute observations during the time frame Psychiatrist D ordered 1:1 Observation, 6/6/21 at 6:00 PM through 6/6/21 at 10:46 PM, and documentation review on 4 additional patients (Patient #13, Patient #14, Patient #15, and Patient #16) hospitalized on the same unit (the only psychiatric unit open in June 2021) revealed the hospital failed to provide 1:1 Observation.

On 6/6/21 at 6:00 PM through 8:15 PM Adult Unit, MHT P and MHT Q provided observation checks for 5 patients located in various locations of the adult psychiatric unit. MHT P and MHT Q had not maintained 1:1 observation and stayed within 1 arm's length of Patient #12.

Review of the "Observation Record Inpatient" documents revealed the following:

a. Patient #12's "Observation Record Inpatient," revealed on 6/6/21, that Patient #12 required 1:1 observation, revealed MHT P documented Patient #12 was in the activity yard at 6:00 PM (on a different floor than the inpatient unit); Patient #12 was in the Quiet Activity Room at 6:15 PM, 7:15 PM, 7:30 PM, and 7:45 PM; and the noisy activity room at 6:31 PM. MHT Q documented that Patient #12 was in the bathroom at 6:46 PM and 7:00 PM; in the quiet activity room at 8:00 PM; and the noisy activity room at 8:15 PM.

b. Patient #13's "Observation Record Inpatient," revealed on 6/6/21, that Patient #13 required observation every 15 minutes, revealed MHT P documented Patient #13 was in the noisy activity room at 6:00 PM (despite MHT P documenting they observed patients in the dining room on a separate floor at the same time), 6:15 PM, 6:31 PM, 7:15 PM, 7:30 PM, and in Patient #13's room at 7:45 PM. MHT Q documented Patient #13 was in the noisy activity room at 6:45 PM and 8:00 PM; and Patient #13 was in an unidentified location at 7:00 PM and 8:15 PM.

c. Patient #14's "Observation Record Inpatient," revealed on 6/6/21, that Patient #14 required observation every 15 minutes, revealed that MHT P documented Patient #14 was in the dining room (on a separate floor from the inpatient unit) at 6:00 PM; in Patient #14's room at 6:15 PM, 6:31 PM, 7:15 PM, 7:30 PM, and 7:45 PM. MHT Q documented Patient #14 was in Patient #14's room at 6:45 PM and 7:00 PM; in the noisy activity room at 8:00 PM, and in the group therapy room at 8:15 PM.

d. Patient #15's "Observation Record Inpatient," revealed on 6/6/21, that Patient #15 required observation every 15 minutes, revealed that MHT P documented Patient #15 was in the dining room (on a separate floor from the inpatient unit) at 6:00 PM; in the noisy activity room at 6:15 PM, 6:31 PM, 7:15 PM, and 7:30 PM; and in Patient #15's room at 7:45 PM. MHT Q documented Patient #15 was in the noisy activity room at 6:45 PM and 7:00 PM; and in Patient #15's room at 8:00 PM.

e. Patient #16's "Observation Record Inpatient," revealed on 6/6/21, that Patient #16 required observation every 15 minutes, revealed that MHT P documented Patient #16 was at the Medication Window at 6:00 PM; in the quiet activity room at 6:15 PM and 8:31 PM; and in the noisy activity room at 7:15 PM, 7:30 PM, and 7:45 PM. MHT Q documented Patient #16 was in the unit hallway at 6:45 PM; in the noisy activity room at 7:00 PM and 8:15 PM; in the quiet activity room at 8:00 PM; and in the noisy activity room at 8:15 PM.



11. During an interview on 8/11/21 at 2:40 PM, MHT P indicated that if a patient was on 1:1 observation, a nursing staff member must be within arm's reach of the patient at all times, even if the patient is taking a shower or using the bathroom. Frequently, MHT P is the only MHT assigned to their unit and is very difficult to provide the ordered observation level to patients.

12. During an interview on 8/11/21 at 2:00 PM, MHT D verbalized their understanding that 1:1 observation means that the staff member is "attached at the hip" with that patient.

13. During an interview on 8/16/2021 at 2:13 PM, RN G revealed Patient #1 attempted to kill themselves on 7/23/21. Psychiatrist F was present on the inpatient unit at the time Patient #1 attempted to kill themselves. Following Patient #1's suicide attempt, Psychiatrist F ordered the nursing staff to provide Patient #1 with 1:1 observation, and documented their order on the communication white board in the nursing station. A short time later, the CNO walked up to the communication white board, erased the 1:1 observation note Psychiatrist F wrote, and the CNO wrote in "line of sight" for Patient #1's observation level. When Psychiatrist F discovered the CNO erased Psychiatrist F's note indicating Patient #1 required 1:1 observation, Psychiatrist F returned to the nursing station, erased "line of sight," rewrote "1:1 observation," initialed the note, and documented the date/time.


14. During an interview on 8/16/2021 at 11:12 AM, Psychiatrist F revealed they had concerns about the staffing in the inpatient psychiatric nursing units. On prior occasions, when patients needed 1:1 observation, Psychiatrist F wanted to order 1:1 observation for the patients, but the nursing staff informed Psychiatrist F they could not provide patients with 1:1 observation due to the low staffing levels.

In the case of Patient #1, Psychiatrist F placed an order for the nursing staff to provide Patient #1 with 1:1 observation in Patient #1's medical record and also documented the order on the communication white board in the nursing station. Later, the nursing staff informed Psychiatrist F that the CNO erased Psychiatrist F's order for 1:1 observation from the communication white board. Psychiatrist F returned to the nursing station and discovered Psychiatrist F's order for 1:1 observation on Patient #1 was missing. Psychiatrist F rewrote the order for 1:1 observation, initialed the order, and dated/timed the note. Psychiatrist F also checked to verify the nursing staff had not discontinued Psychiatrist F's order for 1:1 observation in Patient #1's medical record.